Young People and Substance Use

In 2021, there were 2,000 kids under the age of 18 held in jails, and approximately 85% of them were being held as adults.⁸⁴ While some states refuse to adopt a policy to house juveniles separate from adults, many have acknowledged the immense potential for harm.⁸⁵

• Approximately 292 children were held in adult prisons in 2021, an 85% decline over 10 years (see Table 33).
• More than half of all children in adult prisons were held in just five states: Florida, Connecticut, Ohio, Mississippi, and Arizona.
• Children housed in adult jails/prisons are 36 times more likely to commit suicide than those placed in juvenile facilities. ⁸⁶

However, regardless of their place of containment, they are at increased risk for physical and psychological harm by confining young people, cutting them off from their families, disrupting their education, and exposing them to further trauma and violence. These practices harm their development and have, in most cases, lifelong negative consequences.⁸⁷ For this reason, juvenile courts and facilities are most appropriate and more cost-effective for children and youth facing incarceration, as their exposure to adult facilities increases the risk of suicide, sexual assault, and re-arrest later in life.⁸⁸

Some statutes mandate the sight and sound separation between children and adults in adult correctional facilities to protect children from acts of sexual and physical violence, a policy which subjects thousands of youths to solitary confinement and significant psychological trauma. Incarcerating youth can be counterproductive in that it undermines public safety, damages young people’s physical and mental health, and impedes their educational and career success.⁸⁹

'There were 72.5 million children in the United States in 2022, which was 0.4 million less than in 2021. The total number of children is projected to increase to 78.2 million in 2050. In 2022 (the latest year of data available at the time of publication), there were fewer children in the 0–5 age group (22.4 million) than in the 6–11 age group (24.2 million) or the 12–17 age group (25.8 million).

"Since the mid-1960s, children have decreased as a proportion of the total U.S. population. In 2022, children made up 22% of the population, down from a peak of 36% at the end of the Baby Boom, in 1964. Children’s share of the population is projected to continue its slow decline through 2050, when children are projected to make up 20% of the population.

"Racial and ethnic diversity has grown dramatically in the United States in the last 3 decades. This growth was first evident among children. In 2022, 49% of U.S. children were White, non-Hispanic; 26% were Hispanic; 14% were Black, non-Hispanic; 6% were Asian, non-Hispanic; and 6% were non-Hispanic “All other races.”

"This population is projected to become even more diverse in the decades to come. Whereas the percentages of children in most of the other racial and ethnic origin groups have declined, the percentage of children who are Hispanic has grown substantially, increasing from 9% of the child population in 1980 to 26% in 2022. In 2030, less than half of all children are projected to be White, non-Hispanic. By 2050, it is projected that 39% of all children will be White, non-Hispanic; 31% will be Hispanic; 14% will be Black, non-Hispanic; 7% will be Asian, non-Hispanic; and 9% will be non-Hispanic 'All other races.'"

"The present study is the first to compare the clinical profiles of SUD+PTSD [Substance Use Disorder + Post Traumatic Stress Disorder] individuals with a history of CT [Childhood Trauma] to those with a history of adulthood only trauma. In line with previous research in the substance use literature, participants reported alarmingly high rates of CT exposure (77%) and childhood sexual abuse (55%) (Karadag et al., 2005; Medrano et al., 1999; Plotzker et al., 2007; Wu et al., 2010). Nonetheless, it is possible that these are actually underestimates of the true prevalence as these data are based on retrospective recall. Studies that have compared retrospective self-report against court records of abuse have shown that people often underreport histories of childhood sexual and physical abuse (Widom & Morris, 1997); (Widom & Shepard, 1996).

"The median age of onset of trauma exposure was 8 years, highlighting the importance of screening for trauma exposure in children by health care providers. Early detection is necessary so that early interventions may be implemented that may prevent that development of subsequent trauma-related mental health problems.

"The mental health of participants in the present study was poor. Consistent with previous studies of SUD+PTSD samples, there were high rates of depression (Brady, Killeen, Saladen, Dansky, & Becker, 1994; Tarrier & Sommerfield, 2003), anxiety (Najavits et al., 1998; Tarrier & Sommerfield, 2003) and BPD (Van Den Bosch, Verheul, Langeland, & Van Den Brink, 2003). Important differences were observed in relation to trauma, PTSD and substance use. The CT+ group experienced more trauma types in their lifetime compared to the CT− group. This finding is in accordance with a large body of literature that has found associations between CT, particularly CSA, and risk of re-traumatisation in adulthood (Arata, 2002; Desai, Arias, Thompson, & Basile, 2002; Jankowski, Leitenberg, Henning, & Coffey, 2002; Messman & Long, 1996). This is of clinical importance, as re-traumatisation has been associated with more complex PTSD symptom presentation (Briere, Kaltman, & Green, 2008; Cloitre et al., 2009; Gibson & Leitenberg, 2001), and other co-occurring anxiety disorders, such as generalised anxiety disorder, simple phobia and social phobia, as well as higher rates of suicide attempts and depression (Cloitre, Scarvalone, & Difede, 1997).

"As expected, the CT+ group had also experienced PTSD symptoms for a longer period of time, highlighting the chronic and pervasive nature of PTSD associated with CT. Despite having suffered PTSD for an average of 10 years very few had accessed treatment, highlighting an area of unmet need.

"Individuals with a history of CT presented with a more severe clinical profile in relation to a number of substance use characteristics when compared to those who experienced trauma confined to adulthood. The CT+ group had an earlier age of onset of substance use, had more extensive polydrug use histories, and a greater severity of dependence. These findings emphasise the long term effects and clinical implications associated with early trauma experiences and substance use. Given these findings it is not surprising that participants in the CT+ group also had higher rates of previous drug treatment episodes, which may indicate that current treatment programs are not addressing the needs of those who have a history of CT (Mills et al., 2005). The additional service utilisation among CT+ individuals translates into higher costs for the health care system, emphasising the need for appropriate treatment to be provisioned to this group (Hidalgo & Davidson, 2000)."

The United States persists in incarcerating children and youth despite overwhelming evidence of its ineffectiveness in steering them away from further system involvement.⁸¹ Although the number of youths arrested and incarcerated has declined significantly between 2000 and 2020, the decline is not spread equitably across all demographics. Children of color are especially vulnerable to overcriminalization and therefore overrepresentation on every front:

• Of the 265,600 children arrested in the United States in 2021, 1 in 3 were Black children, though Black children constitute only 15% of the nation’s youth population.
• Fully two-thirds (67%) of children in the juvenile justice system are children of color (see Table 35). 
• 41% of youth in custody (ex. juvenile justice and detention centers, jails and prisons) are Black. ⁸²
• Black youth are more likely to be in custody than White youth in every state but Hawaii.
• The national youth placement rate of 114 per 100,000 masks a massive racial disparity. The Black youth placement rate of 315 per 100,000 eclipses the White youth placement rate of 72 per 100,000. ⁸³
• Only 7% of child arrests were for violent crimes.

"As shown in Figure 13, a total of 420 JDCs were operating across the United States in 2014. This number decreased to 305 by 2019 and again to 296 by the end of 2021. These data indicate a 3% decrease in JDCs between 2019 and 2021. Overall, between 2014 and 2021, the number of JDCs in the United States decreased by 30%."

"Prevalence of past-12 month use of ketamine (another “club drug”) among 12th grade students has been below 2% for the past decade and in 2022 stood at 1.2%. This “club drug” was added to the survey in 2000. It showed little change in its usage levels through 2002. Since then use has declined in all grades. Because of the very low levels of use of this drug by 2011, questions about its use were dropped from the questionnaires administered to 8th and 10th graders."

"In Vancouver and Lisbon, there are other critical gaps in harm reduction services and programs for YPWUD as well. In both settings, youth-dedicated safer injection, safer smoking, and overdose prevention sites do not exist. The COVID-19 pandemic prompted a scaling up of harm reduction initiatives in both Vancouver and Lisbon [9, 16]. And yet, in Lisbon, interventions such as a new shelter that includes access to a safer consumption space (via a mobile drug consumption room) was not designed to include youth. In Vancouver, even when YPWUD are allowed to use those safer consumption sites that do exist, they often don’t feel comfortable in these adult-oriented spaces.

"In our experience, adult-oriented safer consumption spaces can be intimidating for YPWUD, who don’t always feel like they can ask questions or get appropriate help in these places. In adult-oriented spaces, it can seem like everyone already knows what they are doing and what they want to be doing when it comes to their substance use, and many YPWUD feel like they have to imply that they are equally experienced and confident in their decisions about drugs when they are in these places. YPWUD may also worry that if they access adult-oriented safer consumption spaces, someone might report them to child protective services, or tell a family member, caregiver, provider, or worker that they were seen there. In Vancouver, we have seen YPWUD turned away from adult-oriented safer consumption spaces because they looked "too young" and “too healthy” to be using drugs intensively, or “didn’t have any track marks.” When YPWUD are uncomfortable or actively turned away, it can drive them even further away from life-saving care. It can also send the message that their lives are not worth saving.

"In Portugal, safer drug consumption spaces in general are not widely available (the first safer smoking and injecting sites were opened in 2021), and there are no youth-dedicated spaces. Drug checking is only available in Lisbon, and take-home naloxone kits and peer-to-peer overdose prevention (naloxone) programs are also not available despite ongoing advocacy. In both Vancouver and Lisbon, there has been a primary focus on connecting people who use drugs with OAT and sterile drug use paraphernalia. As others have argued, the focus is on mediating drug-related risks and harms (e.g., syringe sharing, blood borne infections), and treating substance use “disorders” via licit replacement therapies (e.g., methadone, buprenorphine-naloxone), rather than on making the use of substances such as heroin, fentanyl, crack, and meth safer via safe supply and harm reduction programs [11]. In both settings, a focus on substance use as either criminal or pathological undermines the self-determination of YPWUD in relation to their drug use, harm reduction, and care."

"Using the Substance Abuse and Mental Health Services Administration’s treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly."

Table: Estimated Prevalence of Monthly Use of Various Drugs by US Eighth Graders in the US

" A majority of 12th graders perceive that regular use of many drugs entails a great risk of harm for the user. In 2022, as Table 8-3 shows, 84% of 12th graders perceive a great risk of harm from regular use of heroin, and 77% for cocaine. More than half (60%) of 12th graders attribute great risk to regular use of LSD, and about half (52%) do so for regular use of amphetamines. About half (54%) of all 12th graders think that regular use of sedatives (barbiturates) involves a great risk of harm to the user. The perceived risk of marijuana is relatively much lower, with a little more than one in four 12th graders (28%) ascribing great risk to regular use.

" Almost three out of four 12th graders (72%) judge smoking one or more packs of cigarettes per day as entailing a great risk of harm for the user in 2022. This level of perceived risk is not much lower than the same perceived risk level for regular use of cocaine (77%).

" Levels of perceived risk for regular nicotine vaping are substantially less than the levels for regular cigarette use of one or more packs a day. In 2022, 45% of 12th graders perceived a great risk from regular nicotine vaping, compared to 72% for regular cigarette use.

" Marijuana vaping ranks as having a relatively lower risk for regular use among 12th grade students in comparison to nicotine vaping. In 2022, 36% considered it to involve “great risk.”

" Regular use of alcohol is more explicitly defined in several questions providing specificity on the amount and frequency of use. About one in five 12th graders (23%) associate great risk of harm with having one or two drinks nearly every day, about 1 in 3 (35%) think there is great risk involved in having five or more drinks once or twice each weekend, and about 2 in 3 (67%) think the user takes a great risk in having four or five drinks nearly every day. Still, it is noteworthy that about 1 in 3 (33%) do not view having four or five drinks nearly every day as entailing great risk. None of these measures significantly changed from 2021 to 2022."

Table: Estimated Prevalence of Daily Use of Various Drugs By US Youth In Grades 8, 10, and 12 Combined

Table: Annual Prevalence of Use of Various Drugs by US Youth in Grades 8, 10, and 12 Combined

"Among 207,781 national YRBS [Youth Risk Behavioral Survey] respondents (mean [SD] age, 16.04 [1.23] years; 50.90% male), 13.35% were Black or African American, 17.09% were Hispanic, and 60.13% were non-Hispanic White. Among 1 549 075 state YRBS respondents (mean [SD] age, 16.01 [1.23] years; 50.20% male), 16.53% were Black or African American, 17.78% were Hispanic, and 58.09% were non-Hispanic White.

"Based on the national YRBS, RML [Recreational Marijuana Laws] adoption was not associated with current marijuana use (odds ratio, 0.97; 95% CI, 0.85-1.10) or frequent marijuana use (odds ratio, 0.98; 95% CI, 0.83-1.16) (Table). Estimates based on the state YRBS and estimates of the association between the first dispensary opening and marijuana use were qualitatively similar (Table). Interaction-weighted estimates were similar to their logistic regression counterparts (Table).

"Based on the national YRBS and using lead and lag indicators in place of the RML indicators, there was no association between RMLs and marijuana use during the prelegalization period (Figure), suggesting the parallel-trends assumption held. After legalization, there was no evidence of an increase in marijuana use.

" Substantial differences were found in perceived availability of the various drugs (Tables 9-10 to 9-12). In 2022 the percentage of 12th graders reporting it would be fairly easy or easy to get a drug varied from 12% or less for heroin, crack, and crystal methamphetamines to 69% and above for alcohol, vaping devices, and marijuana.

" In general, the more widely used drugs are reported to be available by higher proportions of the age group, as would be expected. The substances with the highest levels of use in 2022, specifically marijuana, alcohol, and vaping devices, also place in the top three in terms of perceived availability.

" Older adolescents generally perceive drugs to be more available. For example, in 2022, 26% of 8th graders said marijuana would be fairly easy or very easy to get (which we refer to as “readily available”), versus 49% of 10th graders and 70% of 12th graders.

" Higher availability among both the more widely used drugs and also older age groups is consistent with the notion that availability is largely attained through friendship circles. (Friends clearly are the leading source through which 12th graders obtain prescription drugs, as discussed above.) The differences among age groups may also reflect less willingness and/or motivation on the part of those who deal drugs to establish contact with younger adolescents.

" Marijuana appears to be readily available to the great majority of 12th graders; in 2022, 70% reported that they think it would be very easy or fairly easy to get—far higher than the proportion who reported ever having used it (38%).

" There is a considerable drop in availability after marijuana, alcohol, cigarettes, and vaping; the next most readily available class of drugs for 12th graders is amphetamines, with 33% saying these drugs would be very or fairly easy to get, followed by hallucinogens other than LSD (31%).

" Substances with the lowest availability among 12th grade students in 2022 are crystal methamphetamine (8%), crack (11%), heroin (12%), cocaine powder (12%), and steroids (16%).

" In each grade similar percentages of students reported they could fairly or very easily get a vaping device, e-liquids with nicotine, or flavored vaping solutions. In 8th grade the percentage were, respectively, 35%, 33%, and 31%. In 10th grade they were 52%, 51%, and 49%. In 12th grade they were 69%, 67%, and 66%.

" In 2022, 34% of 8th graders, 48% of 10th graders, and 54% of 12th graders thought that cigarettes would be fairly easy or very easy for them to get if they wanted some.

" Alcohol has the highest level of availability in each grade. The percentage saying it would be fairly easy or very easy to get in 8th grade was 42%, in 10th grade was 59%, and in 12th grade was 78%.

" Drug availability levels are lowest in 8th grade. Even so, in 2022 marijuana was reported as readily available by about one in four (26%) 8th grade students.

" Because many inhalants—such as glues, butane, and aerosols—are universally available, we do not ask about their availability. See Table 9-12 for the full list of drugs included in the questions for 12th graders; a few of these drugs were not asked of the younger students (see Tables 9-10 and 9-11)."

"Concerns about laws and policy measures that may inadvertently affect youth drug use merit careful consideration. Our study does not show evidence of a clear relationship between legalization of marijuana for medical purposes and youth drug use for any age group, which may provide some reassurance to policymakers who wish to balance compassion for individuals who have been unable to find relief from conventional medical therapies with the safety and well-being of youth. Further research is required to track the trends in marijuana use among adolescents, particularly with respect to different types of marijuana laws and implementation of laws in each state."

"• Among state prisoners, an estimated 3 in 5 white (60%) and Hispanic (62%) females and about 1 in 2 black (50%) females were mothers with minor children (table 3).

"• In state prison, 48% of black males, 51% of Hispanic males, and 40% of white males reported having a minor child.

"• Nearly 7 in 10 Hispanic (67%) females in federal prison were mothers with minor children, compared to about 1 in 2 white (49%) and black (54%) females.

"• Among federal prisoners, about 3 in 5 black (64%) and Hispanic (64%) males and 3 in 10 white (34%) males were fathers with minor children.

"• The average age of a minor child among parents in state prison was 9 years old (table 4).

"• Among minor children of parents in state prison, 1% were younger than age 1, about 18% were ages 1 to 4, and 48% were age 10 or older.

"• The average age of a minor child among parents in federal prison was 10 years old.

"• An estimated 13% of minor children of federal prisoners were age 4 or younger, and 20% were ages 15 to 17."

"Marijuana has been one of the most consistently available drugs and has shown only small variations over the years (see Tables 9-10 through 9-12 and Figure 9-5a). The nine point drop in 12th grade after the pandemic from 79% in 2019 to 70% in 2021 stands out as the largest two-year decrease for this measure over the life of the study. This lower level persisted in 2022. Previous to the pandemic between 80% and 90% of American 12th graders since 1975 reported they could readily obtain marijuana.

"While variability has been small over the course of the survey, perceived availability of marijuana is at or near historic lows in each grade. In 2022 in 8th grade it was 26% (a historic low), in 10th grade it was 49% (the second lowest level recorded by the survey, just above the 2021 low), and in 12th grade it was at 70% (the lowest level ever recorded by the survey). In 10th grade a survey mode effect resulting from the switch to electronic data collection in 2019 indicates estimates based on electronic data collection are seven points lower than those based on paper-and-pencil (see the ‘2019p’ and ‘2019e’ columns in Table 9-11), but even with addition of seven points to the 2021 and 2022 estimates they remain lower than any of the paper-and-pencil estimates since first measured in 1992. These declines in perceived availability are somewhat counter-intuitive and unexpected, given the widespread adoption of medical marijuana laws and recent legalizing of recreational marijuana use for adults in many states. Because most states that have legalized marijuana in some fashion have set a minimum age of 21 for purchase it would apply to the great majority of respondents in grades 8 through 12. Perhaps the emergence of legally sanctioned sale has reduced the size of the market for illicit purchases, resulting in less overall availability to minors."

"The prevalence of lifetime substance use among adolescents in 2018 was 26.3% (95% CI, 25.4-27.2) for alcohol, 15.4% (95% CI, 14.7-16.1) for cannabis, and 13.4% (95% CI, 12.7-14.1) for tobacco; among young adults in 2018, prevalence of lifetime substance use was 79.7% (95% CI, 78.9- 80.5) for alcohol, 51.5% (95% CI, 50.4-52.6) for cannabis, and 5.0% (95% CI, 53.9-56.1) for tobacco. Prevalence of SUDs differed by substance, age group, and time since initiation. Adjusted prevalence of cannabis use disorder was higher among adolescents than among young adults within 12 months of initiation (10.7%; 95% CI, 9.3-12.3 vs. 6.4%; 95% CI, 5.2-7.9) and at more than 36 months (20.1% [95% CI, 18.0-22.3] vs. 10.9% [95% CI, 10.3-11.4]) (Table). Prevalence of alcohol use disorder and nicotine dependence did not differ between the 2 groups within 12 months of initiation but was higher for young adults in subsequent periods.

"Among young adults, prevalence of lifetime cocaine, methamphetamine, and heroin use in 2018 was 11.4% (95% CI, 10.7-12.1), 2.5% (95% CI, 2.2-2.8), and 1.3% (95% CI, 1.1-1.5), respectively. Within 12 months of initiation, adjusted prevalence was higher for methamphetamine use disorder (24.8% [95% CI, 16.8-34.9]) and heroin use disorder (30.9% [95% CI, 20.6-43.4]) than for cocaine use disorder (5.6% [95% CI, 4.2-7.4]). Estimates for adolescents were not reported owing to limited samples.

"Prevalence of lifetime misuse of prescription drugs in 2014 was 9.2% (95% CI, 8.7-9.7) among adolescents and 26.3% (95% CI, 25.4-27.2) among young adults. Among the population with lifetime misuse, adjusted prevalence of prescription opioid use disorder, prescription stimulant use disorder, and prescription tranquilizer use disorder were consistently higher for adolescents than for young adults (Figure). Prevalence since time of initiation for adolescents was stable for prescription opioid use disorder and decreased for prescription stimulant use disorder and prescription tranquilizer use disorder, whereas for young adults, prevalence increased for prescription opioid use disorder and was stable for prescription stimulant use disorder and prescription tranquilizer use disorder."

"• Although 62 percent of children arrested in the U.S. were white, children of color were nearly two times more likely to be arrested than white children.⁵ Black children were two and a half times more likely.⁶ 

"• In 2017, the residential placement rate for children of color was more than two times that for white children nationwide and more than four times that for white children in 18 states and the District of Columbia. Black children were committed or detained at nearly five times the rate of white children.⁷ 

"• Two-thirds (67 percent) of children in the juvenile justice system were children of color: 41 percent were Black and 21 percent were Hispanic (see Table 34). 

"• Children of color are also disproportionately transferred to the adult criminal justice system, where they are tried and prosecuted as adults. In 2017, Black youth represented 54 percent of youth prosecuted in adult criminal court but only 15 percent of the total youth population.⁸ Black youth are nine times more likely than white youth to receive an adult prison sentence; American Indian/Alaska Native youth are almost two times more likely and Hispanic youth are 40 percent more likely.⁹"

"Boys, youth with disabilities and LGBTQ youth also come into disproportionate contact with juvenile and adult criminal justice systems.

"• In 2017, the residential placement rate for boys was more than five times that for girls. Eighty-five percent of children in residential placement were male.¹⁰

"• At least 1 in 3 youth in the juvenile justice system has a disability qualifying them for special education services under the Individuals with Disabilities Education Act (IDEA)—nearly four times the rate of youth in public schools. Less than half receive special education services while in custody.¹¹

"• The percent of LGBTQ children in the juvenile justice system (20 percent) is more than two times that of LGBTQ youth in the general population (7-9 percent); 85 percent are children of color.¹²"

"'Noncontinuation' refers to not using a drug in the prior 12 months after having used it at some earlier time in one’s life. In other words, the noncontinuation rate is the percent of lifetime users who did not report using the drug in the past 12 months (or in the case of cigarettes, in the past 30 days). These rates and the changes in them over the years are shown in Table 6-5a for lifetime users; in Table 6-5b the noncontinuation rates are based on 12th graders who are “experienced users” (i.e., used the drug 10 or more times in their lifetime). An important caution is that these estimates are based on students who have ever used specific drugs, and the estimates can vary substantially from year to year for drugs with lower prevalence and thus small numbers of cases.

"• The noncontinuation rate for nicotine vaping in 2022 was 30%, similar to where it was in 2021 at 31%. This level represents more than a doubling since 2019, when it was 14%. Since 2019 the prevalence of nicotine vaping plateaued and then began to decline. These results suggest that in recent years the decline in adolescent nicotine vaping partly stems from the increasing percentage of adolescents who discontinued use after initiating use.

"• Noncontinuation had to be defined differently for cigarettes because respondents are not asked to report on their cigarette use in the past year. The noncontinuation rate is thus defined as the percentage of those who say they ever smoked in their lifetime who also reported not smoking at all during the past 30 days rather than the past year. In 2022 noncontinuation of cigarettes continued its long term increase and was at 76%, a level second only to 2021 when it was 77%.

"• Noncontinuation of smokeless tobacco was near its highest recorded level in 2022 at 69%. One possibility is that nicotine vaping is displacing teen use of cigarettes and smokeless tobacco, a hypothesis that warrants close consideration.

" The noncontinuation rate for marijuana vaping has more than doubled in the past four years, from 12% in 2019 to 25% in 2022. Part of the reason for these increased rates may be the outbreak of vaping related lung injury in 2020, which was linked to marijuana vaping. Since 2019 the prevalence of marijuana vaping has plateaued after marked increases in 2018 and 2019. As with nicotine vaping, these results suggest that in recent years the decline in adolescent marijuana vaping partly stems from the increasing percentage of adolescents who discontinued use after initiating use.

"• Marijuana use overall—that is, without the question specifying any specific method of use—has one of the lowest rates of noncontinuation of all drugs (Table 6-5a). In 2022, the noncontinuation rate was only 20%, and has hovered in a narrow window between 18% and 26% over the last two decades.

"During the 1990s, marijuana noncontinuation rates fell by half, from a high of 35% in 1991 to a low of 17% in 1995, indicating that the substantial increase in prevalence during this period represented not only an increase in youth adopting marijuana use, but also sharply lower levels of users desisting from it. Previous to 1992, noncontinuation had gradually increased since the early 1980s, and with these higher rates of noncontinuation came a decrease in marijuana prevalence during those same years."

"Data on youth marijuana use was available from two sources. The Healthy Kids Colorado Survey (HKCS), with 47,146 high school and 6,704 middle school students responding in 2017, and the National Survey on Drug Use and Health (NSDUH), with about 512 respondents in 2015/16.

"HKCS results indicate no significant change in past 30‐day use of marijuana between 2013 (19.7%) and 2017 (19.4%). Also, in 2017, the use rates were not different from the national 30‐day use rates reported by the Youth Risk Behavior Survey.² In 2017, 19.4% of Colorado high school students reported using marijuana in the past 30‐days compared to 19.8% of high school students nationally that reported this behavior.

"The 2017 HKCS found that marijuana use increases by grade level, with 11.0% of 9th graders, 17.7% of 10th graders, 23.7% of 11th graders, and 25.7% of 12th reporting use in the past 30‐days.

"The 2015/16 NSDUH, with many fewer respondents compared to HKCS, indicated a gradual increase in youth use from 2006/07 (9.1%) to 2013/14 (12.6%); however, the last two years showed decreased use, with 9.1% reporting use in 2015/16. The NSDUH showed that youth use of marijuana in Colorado (9.1%) was above the national average (6.8%)."

"The percentage of youth who have used marijuana in the past 12 months did not return to 2020 levels in 2022. Lifetime and past 12-month prevalence stayed steady or edged slightly upward in 2021, and prevalence in 2022 remained closer to 2021 than 2020 levels. Lifetime prevalence in 2022 was 11% in 8th grade, 24% in 10th grade, and 38% in 12th grade.

"The lower prevalence levels in 2021 and 2022 mark the first substantial change in past 12-month marijuana prevalence in more than a decade; previous to 2021 marijuana levels had hovered without any systematic trending for about a decade.

"Levels of annual marijuana use today are considerably lower than the historic highs observed in the late 1970s, when more than half of 12th graders had used marijuana in the past 12 months. This high point marked the pinnacle of a rise in marijuana use from relatively negligible levels before the 1960s.

"Daily marijuana use, defined as use on 20 or more occasions in the past 30 days, held steady in 2022 after substantial declines in 2021. In all grades 2022 levels remained below those in 2019 and 2020, when all surveys were collected before the start of the national social distancing policies on March 15, 2020.

"The prevalence of using marijuana daily for a month or more during one's lifetime is reported for 12th graders only. That prevalence was at 21% when first measured in 1982, declined sharply to just 8% by 1992, and rose back to 19% by 1997, followed by a long gradual decline to 12% by 2018, before leveling. It stood at 14% in 2022.

"2020 prevalence levels are not reported for daily marijuana use for a month due to low sample size that resulted from curtailed data collection due to the pandemic.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns."

"Despite the relatively progressive policy landscapes of both Vancouver and Lisbon, the soft left hand of low-barrier harm reduction programs continues to be paired with the hard right hand of criminal sanctions and other forms of control in both settings [31]. In Vancouver and Lisbon, police are often tasked with identifying “problem” YPWUD [Young People Who Use Drugs] and making referrals to services [11]. While accessing these services is technically voluntary in Portugal, physically presenting oneself before the Commissions for the Dissuasion of Drug Addiction is mandatory for those who are caught using drugs (including cannabis), and accepting “invitations to treatment” can be enforced by fines and other kinds of sanctions. In fact, the last decade has seen a sharp increase in criminal sanctions targeted at people who use drugs in Portugal, despite decriminalization [11].4 In Vancouver, people who use drugs in the context of street involvement continue to be heavily criminalized, and as mentioned above, there have been growing calls for the decriminalization of substance use in this setting [15].

"Youth-dedicated drop-in centers and “one-stop-shop” service hubs that prioritize harm reduction are a better primary point of care for YPWUD than hospitals or criminal justice facilities. These kinds of centers and hubs do exist in Vancouver. They provide a range of harm reduction, drug use, mental health, and social services and are critical supports for YPWUD in this setting. In Portugal, harm reduction programs and centers are more explicitly targeted towards higher-income and older (> 18 years of age) YPWUD, such as those who use drugs at music festivals. In Lisbon, YPWUD in the context of street involvement have largely been left out of efforts to scale up harm reduction interventions, including in response to the COVID-19 pandemic [16]."

"Consistent with the results of previous researchers,² there was no evidence that the legalization of medical marijuana encourages marijuana use among youth. Moreover, the estimates reported in the Table showed that marijuana use among youth may actually decline after legalization for recreational purposes. This latter result is consistent with findings by Dilley et al⁴ and with the argument that it is more difficult for teenagers to obtain marijuana as drug dealers are replaced by licensed dispensaries that require proof of age.⁶"

" Annual marijuana use differs little by race/ethnicity and across the three groups varies between 7% and 8% in 8th grade, 13% and 19% in 10th grade, and 26% and 33% in 12th grade.

" Both 30-day use of any illicit drug and any illicit drug other than marijuana have similar prevalence levels across the three racial/ethnic groups. For Hispanic, Black/African American, and White 12th grade students the prevalence levels of past 30-day use of any illicit drug in 2022 were 18%, 22%, and 19%, respectively. For the outcomes of any illicit drug other than marijuana the corresponding prevalence levels were 3%, 3%, and 2%.

" White 12th grade students had the highest 12-month prevalence of salvia, Vicodin, Ritalin, crystal methamphetamine, misuse of over-the-counter cough/cold medicines, rohypnol, GHB, steroids, and androstenedione.

" Hispanic 12th grade students have the highest 12-month prevalence for a few drugs, but they are drugs with low prevalence and the difference is small in terms percentage points. For example, they have the highest level of dissolvable tobacco, by a difference of 0.7 percentage points (prevalence is 1.8% for Hispanics compared to 1.1% for Black/African American and White students). They also have the highest level of synthetic marijuana, by a difference of 0.2 percentage points (prevalence is 2.8% for Hispanic, 2.6% for Black/African American and 1.4% for White students).

" Black/African American 12th grade students had higher levels of alcohol use than Hispanics and Whites in 2022. The percentage of 12th grade students who had a drink of alcohol in the past 12 months was 57% for Black/African American teens, compared to 41% for Hispanics and 32% for Whites. Prevalence levels for getting drunk in the past 12 months for the three racial/ethnic groups were 37%, 21%, and 16%, respectively. Prevalence of 50using a flavored alcoholic beverage in the last 12 months was 42%, 28%, and 17%, respectively. Binge drinking in the last 30 days was also highest among Black/African American 12th graders, at 16%, compared to 8% for Hispanics and 5% for Whites.

" Black/African American 12th grade students had higher levels of nicotine use than their White and Hispanic peers. Prevalence of cigarette smoking in the past 30 days in 12th grade was 5% for Black/African American teens, compared to 1.9% for Hispanic and 1.2% for White teens. In recent years nicotine vaping has become the more common way for teens to use nicotine, and in 2022 the prevalence level among Black/African Americans was 25%, compared to 13% for Hispanic and 11% for White students.

" Black/African American 12th grade students had higher levels of use for any prescription drug, with past 12-month prevalence at 5%, compared to 4% for Hispanics and 3% for Whites. This difference is driven in part by amphetamines, for which past 12-month prevalence among Black/African American 12th graders is 3%, compared to 2% for Hispanic and 1% for Whites."

"• Although availability of alcohol among 12th grade students in 2022 was at its second lowest level recorded since first measured in 1999, at 78% it is still very high (Tables 9-10 through 9-12 and Figure 9-5a).

"More substantial changes in the perceived availability of alcohol have taken place among 8th and 10th graders. For 8th graders availability declined from 76% in 1992 to 42% in 2022. The 2022 and 2021 levels were lowered in part by a survey mode effect in which estimates based on electronic data collection are about 7 points lower than estimates based on paperand-pencil surveys (compare columns ‘2019p’ and ‘2019e’ in Table 9-10). Nevertheless, even after adjusting the 2022 estimate by adding 7 points to it, the resulting level of 49% is the lowest recorded for this measure over the life of the survey and substantially lower than the 76% level in 1992. For 10th graders availability is down from the peak level of 90% in 1996 to 59% in 2022 (there was no significant mode effect in 2019 for 10th graders). This may reflect some success in state and local efforts to reduce access by those who are under age, as well as a decline in number of friends who use alcohol. It is worth noting, however, that even after these declines, alcohol remains available to a great many teens.

"Alcohol has long been the substance with the highest level of availability. It has been at 78% or higher up to 2022 in all years since its addition to the 12th grade survey in 1999. Over the past decade it has declined somewhat from 92% in 2009 to 78% in 2022."

"Substance use was common among U.S. high school students during 2019 and varied by substance, year, and demographic groups (Table 1). Among current substance use measures, the highest prevalence estimates were for alcohol (29.2%) and marijuana use (21.7%). Current binge drinking was reported by 13.7% of high school students, and 7.2% reported current prescription opioid misuse. Among lifetime use measures, marijuana use was reported by 36.8% of high school students, followed by misuse of prescription opioids (14.3%) and use of synthetic marijuana (7.3%), cocaine (3.9%), methamphetamine (2.1%), or heroin (1.8%). Lifetime injection drug use was reported by 1.6% of high school students.

"Trend data were available for eight of the 11 substance use measures included in the analyses. Among these measures, current alcohol use, lifetime cocaine, lifetime methamphetamine, lifetime heroin, and lifetime injection drug use decreased during 2009–2019. Lifetime use of synthetic marijuana decreased during 2015–2019. The prevalence of lifetime marijuana use increased during 2009–2013 (36.8%–40.7%) and then decreased during 2013–2019 (40.7%–36.8%). No statistically significant changes from 2017 to 2019 were observed for any of the substance use behaviors.

"Compared with females, males had a significantly higher prevalence of lifetime use of cocaine (4.9% versus 2.7%), methamphetamine (2.7% versus 1.5%), heroin (2.3% versus 1.0%), and injection drug use (2.1% versus 1.1%) (Table 2). Compared with males, females had a significantly higher prevalence of current alcohol use (31.9% versus 26.4%), binge drinking (14.6% versus 12.7%), current prescription opioid misuse (8.3% versus 6.1%), and lifetime prescription opioid misuse (16.1% versus 12.4%). Among racial/ethnic groups, notable differences in prevalence estimates were identified for current use of alcohol, binge drinking, current prescription opioid misuse, and lifetime use of cocaine, methamphetamine, heroin, injection drug use, and synthetic marijuana. However, no clear pattern emerged. For example, the prevalence of current prescription opioid misuse was significantly lower among white students (5.5%) compared with black (8.7%) or Hispanic students (9.8%). Conversely, the prevalence of current alcohol use was lower among black students (16.8%) compared with white (34.2%) or Hispanic students (28.4%).

"Approximately half of the substance use behaviors varied substantially by grade, with consistently higher prevalence among 11th- and 12th-grade students compared with 9th- and 10th-grade students for current marijuana use, current alcohol use and binge drinking, lifetime marijuana use, lifetime cocaine use, lifetime methamphetamine use, and lifetime synthetic marijuana. Prevalence of all but one of the substance use behaviors (i.e., binge drinking) varied considerably by sexual identity. Students who identified as lesbian, gay, or bisexual had a higher prevalence of all substance use behaviors, except binge drinking, compared with students who identified as heterosexual. Similarly, students who identified as not sure of their sexual identity also had higher prevalence of approximately half of the substance use behaviors compared with heterosexual students, including current prescription opioid misuse, lifetime cocaine use, lifetime methamphetamine use, lifetime heroin use, lifetime injection drug use, and lifetime prescription opioid misuse. However, students who identified as not sure of their sexual identity had lower prevalence of certain substance use behaviors compared with students identifying as lesbian, gay, or bisexual, including current marijuana use, current alcohol use, and lifetime marijuana use."

"The perceived availability of cigarettes continued a long-term decline in 8th and 10th grade to historic low levels. After holding fairly steady at very high levels for some years, perceived availability reported by 8th and 10th graders began to decline modestly after 1996, very likely as a result of increased enforcement of laws prohibiting sale to minors under the Synar Amendment and FDA regulations. The proportion of 8th graders saying that they could get cigarettes fairly or very easily fell from 77% in 1996 to 56% in 2010, and was at 43% in 2019. Over the same interval, the decline among 10th graders was from 91% in 1996 to 58% in 2019. These are encouraging changes and suggest that government and local efforts to reduce accessibility to adolescents – particularly younger adolescents – seem to be working.

"In 12th grade the availability of cigarettes also decreased in 2019, although in this grade trend data are available starting in 2017. In 2019, 75% of 12th grade students reported ready availability of cigarettes, down from 78% in 2017. Availability may decline considerably in the coming years as a result of federal legislation signed into law on December 20, 2019 that makes it illegal for a retailer to sell any tobacco product to anyone under 21 years of age. The cigarette availability measures of 2017-2019 serve as a good “before” measure for future evaluations of the impact of this new law."

"Cannabis was the most widely used illicit drug in all ESPAD countries. On average, 16% of students had used cannabis at least once in their lifetime (Table 8a). The countries with the highest prevalence of cannabis use were Czechia (28%), Italy (27%) and Latvia (26%). The lowest levels of cannabis use (2.9-7.3%) were reported in Kosovo, North Macedonia, Iceland and Serbia. On average, boys reported cannabis use to a larger extent than girls (boys 18 % versus girls 13%). This was the case in nearly all countries except for Bulgaria, Slovakia, Malta, the Netherlands and Czechia, where rates were about the same for boys and girls. The largest gender differences (more than 10 percentage points, with higher rates among boys) were found in Georgia and Monaco."

"Past 12-month use of anabolic steroids in 12th grade are similar for males and females, at 1.3% and 0.9%, respectively. Use of other substances for body building and performance is substantially higher for males. In 2022 past 12-month use of androstenedione was 2.8% for males and 1.1% for females, while prevalence of creatine was 18.6% for males and 5.2% for females."

"In the United States, the purchase or public possession of alcohol anywhere is illegal until age 21, except in the company of a parent or legal-age spouse in certain states. Adolescent alcohol use is associated with various negative educational and health outcomes (French and Maclean 2006; Mason et al. 2010; Schilling et al. 2009). The percentage of students in grades 9–12 who reported using alcohol on at least 1 day during the previous 30 days decreased from 42 to 29 percent between 2009 and 2019. In 2019, the percentage of students in grades 9–12 who reported using alcohol on at least 1 day during the previous 30 days 

"• was lower for male students than for female students (26 vs. 32 percent; figure 12); 

"• was lower for Asian students (14 percent) and Black students (17 percent) than for students of all other racial/ethnic groups; 

"• was lower for heterosexual students (29 percent) and students who were not sure about their sexual identity (25 percent) than for gay, lesbian, or bisexual students (34 percent); and • increased with grade level. (Students’ Use of Alcohol)

"The YRBSS asked students in grades 9–12 about their current use of marijuana anywhere as well as the availability of illegal drugs on school property. In 2019, about 22 percent of students in grades 9–12 reported using marijuana at least 1 time during the previous 30 days; the percentage of students who reported that someone had offered, sold, or given them an illegal drug on school property in the previous 12 months was also 22 percent in 2019. These percentages were not measurably different from their corresponding percentages in 2009.

"In 2019, student reports of marijuana use and illegal drug availability varied by student characteristics. For instance, an examination of the data on the availability of illegal drugs on school property reveals differences by student race/ethnicity and sexual identity. Specifically, the percentage of students who reported that illegal drugs were offered, sold, or given to them on school property in 2019 was 

"• higher for students of Two or more races (28 percent) and Hispanic students (27 percent) than for Black students (21 percent) and White students (20 percent), all of which were higher than for Asian students (14 percent; figure 13); and 

"• higher for gay, lesbian, or bisexual students (30 percent) than for students who were not sure about their sexual identity (24 percent) and students who were heterosexual (21 percent). (Marijuana Use and Illegal Drug Availability)"

"• The percentage of public schools reporting the presence of security staff was higher during the 2015–16 school year than during the 2005–06 school year (57 vs. 42 percent). The percentage of schools reporting the presence of sworn law enforcement officers was also higher in 2015–16 than in 2005–06 (48 vs. 36 percent), as was the percentage of schools reporting the presence of a School Resource Officer (42 vs. 32 percent; Spotlight 1).

"• Among secondary schools with any sworn law enforcement officer present at least once a week, a lower percentage of schools in cities reported having an officer who carried a firearm (87  percent) compared with schools in towns (97 percent) and schools in suburban and rural areas (95 percent each; Spotlight 1).

"• Among public schools with any sworn law enforcement officers, a lower percentage of primary schools (51 percent) than of secondary schools (70 percent) reported their school or district had any formalized policies or written documents (such as a Memorandum of Use or Memorandum of Agreement) that outlined the roles, responsibilities, and expectations of sworn law enforcement officers at school (Spotlight 1)."

"• Between 2001 and 2015, the percentage of students ages 12–18 who reported that gangs were present at their school decreased from 20 to 11 percent. The percentage who reported gangs were present at their school was also lower in 2015 than in 2013 (12 percent; Indicator 8).

"• A higher percentage of students from urban areas (15 percent) reported a gang presence than of students from suburban (10 percent) and rural areas (4 percent) in 2015. Additionally, a higher percentage of students attending public schools (11 percent) than of students attending private schools (2 percent) reported that gangs were present at their school in 2015 (Indicator 8).

"• In 2015, higher percentages of Black (17 percent) and Hispanic (15 percent) students reported the presence of gangs at their school than of White (7 percent) and Asian (4 percent) students (Indicator 8)."

"During the 2014–15 school year, there were 22,500 reported alcohol-related discipline incidents in the United States (table 15.5).73 The number of alcohol-related incidents varies widely across jurisdictions, due in large part to their differing populations. Therefore, the rate of alcohol-related discipline incidents per 100,000 students can provide a more comparable indication of the frequency of these incidents across jurisdictions. During the 2014–15 school year, the rate of alcohol-related discipline incidents was 45 per 100,000 students in the United States.

"The majority of jurisdictions had rates between 10 and 100 alcohol-related discipline incidents per 100,000 students during the 2014–15 school year. Two states had rates of alcohol-related discipline incidents per 100,000 students that were below 10: Texas and Wyoming, while six states had rates above 100: Arkansas, Alaska, Missouri, Indiana, Kentucky, and Colorado."

"Nationwide, 3.8% of students had carried a weapon (e.g., a gun, knife, or club) on school property on at least 1 day during the 30 days before the survey (Supplementary Table 18). The prevalence of having carried a weapon on school property was higher among male (5.6%) than female (1.9%) students; higher among white male (5.9%), black male (5.4%), and Hispanic male (4.5%) than white female (1.7%), black female (1.7%), and Hispanic female (2.5%) students, respectively; and higher among 9th-grade male (3.6%), 10th-grade male (4.8%), 11th-grade male (7.1%), and 12th-grade male (7.0%) than 9th-grade female (1.3%), 10th-grade female (1.4%), 11th-grade female (3.0%), and 12th-grade female (1.5%) students, respectively. The prevalence of having carried a weapon on school property was higher among 11th-grade (5.0%) and 12th-grade (4.2%) than 9th-grade (2.5%) students; higher among 11th-grade (5.0%) than 10th-grade (3.2%) students; higher among 11th-grade female (3.0%) than 9th-grade female (1.3%), 10th-grade female (1.4%), and 12th-grade female (1.5%) students; and higher among 11th-grade male (7.1%) and 12th-grade male (7.0%) than 9th-grade male (3.6%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, 3.4% of heterosexual students; 5.9% of gay, lesbian, and bisexual students; and 4.9% of not sure students had carried a weapon on school property (Supplementary Table 18). The prevalence of having carried a weapon on school property was higher among gay, lesbian, and bisexual (5.9%) than heterosexual (3.4%) students. Among female students, the prevalence was higher among lesbian and bisexual (4.9%) than heterosexual (1.4%) students. The prevalence also was higher among heterosexual male (5.0%) than heterosexual female (1.4%) students and higher among not sure male (6.8%) than not sure female (2.2%) students."

"Nationwide, 29.8% of students had had at least one drink of alcohol on at least 1 day during the 30 days before the survey (i.e., current alcohol use) (Supplementary Table 98). The prevalence of current alcohol use was higher among female (31.8%) than male (27.6%) students; higher among black female (24.3%) and Hispanic female (35.9%) than black male (16.9%) and Hispanic male (26.8%) students, respectively; and higher among 9th-grade female (22.0%) and 11th-grade female (36.8%) than 9th-grade male (15.3%) and 11th-grade male (31.6%) students, respectively. The prevalence of current alcohol use was higher among white (32.4%) and Hispanic (31.3%) than black (20.8%) students, higher among white female (33.2%) and Hispanic female (35.9%) than black female (24.3%) students, higher among white male (31.6%) and Hispanic male (26.8%) than black male (16.9%) students, and higher among white male (31.6%) than Hispanic male (26.8%) students. The prevalence of current alcohol use was higher among 10th-grade (27.0%), 11th-grade (34.4%), and 12th-grade (40.8%) than 9th-grade (18.8%) students; higher among 11th-grade (34.4%) and 12th-grade (40.8%) than 10th-grade (27.0%) students; higher among 12th-grade (40.8%) than 11th-grade (34.4%) students; higher among 10th-grade female (28.7%), 11th-grade female (36.8%), and 12th-grade female (41.2%) than 9th-grade female (22.0%) students; higher among 11th-grade female (36.8%) and 12th-grade female (41.2%) than 10th-grade female (28.7%) students; higher among 12th-grade female (41.2%) than 11th-grade female (36.8%) students; higher among 10th-grade male (25.3%), 11th-grade male (31.6%), and 12th-grade male (40.5%) than 9th-grade male (15.3%) students; higher among 11th-grade male (31.6%) and 12th-grade male (40.5%) than 10th-grade male (25.3%) students; and higher among 12th grade male (40.5%) than 11th-grade male (31.6%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, the prevalence of current alcohol use was 29.7% among heterosexual students; 37.4% among gay, lesbian, and bisexual students; and 21.5% among not sure students (Supplementary Table 98). The prevalence of current alcohol use was higher among heterosexual (29.7%) and gay, lesbian, and bisexual (37.4%) than not sure (21.5%) students and higher among gay, lesbian, and bisexual (37.4%) than heterosexual (29.7%) students. Among female students, the prevalence was higher among heterosexual (32.2%) and lesbian and bisexual (39.9%) than not sure (20.6%) students and higher among lesbian and bisexual (39.9%) than heterosexual (32.2%) students. The prevalence also was higher among heterosexual female (32.2%) than heterosexual male (27.7%) students and higher among lesbian and bisexual female (39.9%) than gay and bisexual male (29.5%) students."

"Between 1995 and 2015, the percentage of students who reported being afraid of attack or harm at school decreased overall (from 12 to 3 percent), as well as among male students (from 11 to 3 percent) and female students (from 13 to 4 percent). In addition, the percentage of students who reported being afraid of attack or harm at school decreased between 1995 and 2015 for White students (from 8 to 3 percent), Black students (from 20 to 3 percent), and Hispanic students (from 21 to 5 percent). A declining trend was also observed away from school: between 1999 (the first year of data collection for this item) and 2015, the percentage of students who reported being afraid of attack or harm away from school decreased from 6 to 2 percent overall, from 4 to 1 percent for male students, and from 7 to 3 percent for female students. The percentages of White, Black, and Hispanic students who reported being afraid of attack or harm away from school also decreased during this period (from 4 to 2 percent for White students and from 9 to 3 percent each for Black and Hispanic students).

"Between the two most recent survey years, 2013 and 2015, no measurable differences were found in the overall percentages of students who reported being afraid of attack or harm, either at school or away from school. However, the percentage of male students who reported being afraid of attack or harm away from school was lower in 2015 (1 percent) than in 2013 (2 percent).

"In 2015, a higher percentage of female students than of male students reported being afraid of attack or harm at school (4 vs. 3 percent) and away from school (3 vs. 1 percent). In general, the percentages of students who reported being afraid of attack or harm at school and away from school were not measurably different across racial/ethnic groups. However, a higher percentage of Hispanic students (5 percent) than of White students (3 percent) reported being afraid of attack or harm at school in 2015. Similarly, a higher percentage of Hispanic students (3 percent) than of White students (2 percent) reported being afraid of attack or harm away from school.

"Higher percentages of 6th-graders (5 percent) and 7th- and 8th-graders (4 percent each) reported being afraid of attack or harm at school than did 10th- and 12th-graders (2 percent each) in 2015. The percentage of students who reported being afraid of attack or harm away from school was higher for 8th-graders (3 percent) than for 10th-graders (1 percent)."

"Nationwide, 14.9% of students had been electronically bullied (counting being bullied through texting, Instagram, Facebook, or other social media) during the 12 months before the survey (Supplementary Table 28). The prevalence of having been electronically bullied was higher among female (19.7%) than male (9.9%) students; higher among white female (23.0%), black female (13.3%), and Hispanic female (17.2%) than white male (11.2%), black male (8.4%), and Hispanic male (7.6%) students, respectively; and higher among 9th-grade female (22.3%), 10th-grade female (19.7%), 11th-grade female (19.9%), and 12th-grade female (16.4%) than 9th-grade male (10.9%), 10th-grade male (9.7%), 11th-grade male (8.2%), and 12th-grade male (10.4%) students, respectively. The prevalence of having been electronically bullied was higher among white (17.3%) than black (10.9%) and Hispanic (12.3%) students, higher among white female (23.0%) and Hispanic female (17.2%) than black female (13.3%) students, higher among white female (23.0%) than Hispanic female (17.2%) students, and higher among white male (11.2%) than black male (8.4%) and Hispanic male (7.6%) students. The prevalence of having been electronically bullied was higher among 9th-grade (16.7%) than 10th-grade (14.8%) and 12th-grade (13.5%) students, higher among 9th-grade female (22.3%) and 10th grade female (19.7%) than 12th-grade female (16.4%) students, and higher among 9th-grade male (10.9%) than 11th-grade male (8.2%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, 13.3% of heterosexual students; 27.1% of gay, lesbian, and bisexual students; and 22.0% of not sure students had been electronically bullied (Supplementary Table 28). The prevalence of having been electronically bullied was higher among gay, lesbian, and bisexual (27.1%) and not sure (22.0%) than heterosexual (13.3%) students. Among female students, the prevalence was higher among lesbian and bisexual (28.5%) than heterosexual (18.6%) students. Among male students, the prevalence was higher among gay and bisexual (22.3%) and not sure (18.2%) than heterosexual (8.8%) students. The prevalence also was higher among heterosexual female (18.6%) than heterosexual male (8.8%) students and higher among lesbian and bisexual female (28.5%) than gay and bisexual male (22.3%) students."

"In 2015, about 21 percent of students ages 12–18 reported being bullied at school during the school year (figure 11.1 and table 11.1). Of students ages 12–18, about 13 percent reported that they were made fun of, called names, or insulted; 12 percent reported being the subject of rumors; 5 percent reported that
they were pushed, shoved, tripped, or spit on; and 5 percent reported being excluded from activities on purpose. Additionally, 4 percent of students reported
being threatened with harm, 3 percent reported that others tried to make them do things they did not want to do, and 2 percent reported that their property was
destroyed by others on purpose.

"In 2015, a higher percentage of female than of male students ages 12–18 reported being bullied at school during the school year (23 vs. 19 percent), as well as being the subject of rumors (15 vs. 9 percent). In contrast, a higher percentage of male than of female students reported being threatened with harm (5 vs. 3 percent).
"Higher percentages of Black students (25 percent) and White students (22 percent) than of Hispanic students (17 percent) reported being bullied at school in 2015. The percentage of students who reported being made fun of, called names, or insulted was also higher for Black students (17 percent) and White students (14 percent) than for Hispanic students (9  percent). The percentage of students who reported being the subject of rumors was higher for Black students (14 percent), White students (13 percent), and Hispanic students (10 percent) than for Asian students (5 percent).

Notes:
^{“Bullying” includes students who responded that another student had made fun of them, called them names, or insulted them; spread rumors about them; threatened them with harm; tried to make them do something they did not want to do; excluded them from activities on purpose; destroyed their property on purpose; or pushed, shoved, tripped, or spit on them.
“At school” includes in the school building, on school property, on a school bus, and going to and from school.
“Cyberbullying” includes students who responded that another student had posted hurtful information about them on the Internet; purposely shared private information about them on the Internet; threatened or insulted them through instant messaging; threatened or insulted them through text messaging; threatened or insulted them through e-mail; threatened or insulted them while gaming; or excluded them online.
In the Youth Risk Behavior Survey (YRBS), bullying was defined for respondents as “when one or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again.” “On school property” was not defined for survey respondents.
Being electronically bullied includes “being bullied through e-mail, chat rooms, instant messaging, websites, or texting.”}

"Nationwide, 1.5% of students had used a needle to inject any illegal drug into their body one or more times during their life (Supplementary Table 129). The prevalence of having ever injected any illegal drug was higher among male (2.0%) than female (0.8%) students; higher among white male (1.4%), black male (2.6%), and Hispanic male (2.1%) than white female (0.5%), black female (1.1%), and Hispanic female (0.9%) students, respectively; and higher among 9th-grade male (2.1%) and 10th-grade male (1.9%) than 9th grade female (0.6%) and 10th-grade female (0.6%) students, respectively. The prevalence of having ever injected any illegal drug was higher among 12th-grade (1.9%) than 11th-grade (1.1%) students and higher among 12th-grade female (1.3%) than 11th-grade female (0.7%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, 1.0% of heterosexual students; 3.4% of gay, lesbian, and bisexual students; and 6.1% of not sure students had ever injected any illegal drug (Supplementary Table 129). The prevalence of having ever injected any illegal drug was higher among gay, lesbian, and bisexual (3.4%) and not sure (6.1%) than heterosexual (1.0%) students. Among female students, the prevalence was higher among lesbian and bisexual (2.3%) than heterosexual (0.4%) students. Among male students, the prevalence was higher among gay and bisexual (5.7%) and not sure (8.0%) than heterosexual (1.5%) students. The prevalence also was higher among heterosexual male (1.5%) than heterosexual female (0.4%) students and higher among gay and bisexual male (5.7%) than lesbian and bisexual female (2.3%) students."

"An estimated 684,500 state and federal prisoners were parents of at least one minor child in 2016 (figure 1, table 1). About 626,800 (47%) males and 57,700 (58%) females in state or federal prison were parents with minor children. Prisoners reported having an estimated 1,473,700 minor children."

"Lifetime use of illicit drugs varied considerably across the ESPAD countries (Table 8a). On average, 17% of ESPAD students reported having used any illicit drug at least once. The highest percentage of students reporting lifetime use of any illicit drug was found in Czechia (29%), followed by Italy (28%), Latvia (27%) and Slovakia (25%). Particularly low levels (10% or less) of illicit drug use were noted in Kosovo, Iceland, North Macedonia, Ukraine, Serbia, Sweden, Norway, Greece and Romania. On average, 19% of boys and 14% of girls had used illicit drugs at least once during their lifetime. In most ESPAD countries, the prevalence rate was higher among boys than girls. Noticeable gender differences were found in Georgia (24% for boys versus 8.8% for girls), Monaco (29% versus 17%), Cyprus (17% versus 7.0%) and Ireland (25% versus 15%)."

"Nationwide, 4.8% of students had used any form of cocaine (e.g., powder, crack,†† or freebase§§) one or more times during their life (Supplementary Table 114). The prevalence of having ever used cocaine was higher among male (6.1%) than female (3.5%) students; higher among white male (5.5%), black male (4.2%), and Hispanic male (8.1%) than white female (3.4%), black female (1.2%), and Hispanic female (4.6%) students, respectively; and higher among 9th-grade male (3.6%), 10th-grade male (5.5%), 11th-grade male (6.6%), and 12th-grade male (8.7%) than 9th-grade female (2.3%), 10th-grade female (2.3%), 11th-grade female (4.1%), and 12th-grade female (5.3%) students, respectively. The prevalence of having ever used cocaine was higher among white (4.4%) and Hispanic (6.3%) than black (2.8%) students, higher among Hispanic (6.3%) than white (4.4%) students, higher among white female (3.4%) and Hispanic female (4.6%) than black female (1.2%) students, and higher among Hispanic male (8.1%) than white male (5.5%) and black male (4.2%) students. The prevalence of having ever used cocaine was higher among 12th-grade (7.0%) than 9th-grade (2.9%), 10th-grade (3.9%), and 11th-grade (5.4%) students; higher among 11th-grade (5.4%) than 9th-grade (2.9%) students; higher among 11th-grade female (4.1%) and 12th-grade female (5.3%) than 9th-grade female (2.3%) and 10th-grade female (2.3%) students; higher among 11th-grade male (6.6%) and 12th-grade male (8.7%) than 9th-grade male (3.6%) students; and higher among 12th-grade male (8.7%) than 10th-grade male (5.5%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, 4.2% of heterosexual students; 8.0% of gay, lesbian, and bisexual students; and 10.4% of not sure students had ever used cocaine (Supplementary Table 114). The prevalence of having ever used cocaine was higher among gay, lesbian, and bisexual (8.0%) and not sure (10.4%) than heterosexual (4.2%) students. Among female students, the prevalence was higher among lesbian and bisexual (5.6%) than heterosexual (3.0%) students. Among male students, the prevalence was higher among gay and bisexual (14.6%) and not sure (15.1%) than heterosexual (5.2%) students. The prevalence also was higher among heterosexual male (5.2%) than heterosexual female (3.0%) students, higher among gay and bisexual male (14.6%) than lesbian and bisexual female (5.6%) students, and higher among not sure male (15.1%) than not sure female (6.0%) students."

"Sixty percent of high school students and 32 percent of middle school students say that students keep, use or sell drugs on their school grounds. For seven of the past eight years, at least 60 percent of high school students have said they attend a drug-infected school."

"The number of juvenile marijuana arrests decreased 16%, from 3,168 in 2012 to 2,655 in 2017. The rate of juvenile marijuana arrests per 100,000 decreased from 583 in 2012 to 453 in 2017 (‐22%).

"The number of White juvenile arrests decreased from 2,146 in 2012 to 1,703 in 2017 (‐21%).

"The number of Hispanic juvenile arrests decreased from 767 in 2012 to 733 in 2017 (‐4%).

"The number of Black juvenile arrests decreased from 202 in 2012 to 172 in 2017 (‐15%)."

"• Nearly half of state prisoners (47%) and more than half of federal prisoners (57%) reported having at least one minor child.

"• In state prison, about 58% of females were parents with minor children, compared to 46% of males.

"• Nearly 3 in 5 females (58%) and males (57%) in federal prison were parents with minor children.

"• Nearly 1.5 million persons age 17 or younger had a parent who was in state or federal prison in 2016.

"• Parents in state or federal prison had an average of two minor children each.

"• An estimated 19% of minor children with a parent in state prison and 13% with a parent in federal prison were age 4 or younger."

"• Parents in state prison had 1,252,100 minor children, and parents in federal prison had 221,600 minor children (table 2).

"• In state prison, fathers reported 1,133,800 minor children and mothers reported 118,300.

"• In federal prison, fathers reported 208,200 minor children and mothers reported 13,400.

"• Among state prisoners, an estimated 3 in 5 white (60%) and Hispanic (62%) females and about 1 in 2 black (50%) females were mothers with minor children (table 3).

"• In state prison, 48% of black males, 51% of Hispanic males, and 40% of white males reported having a minor child.

"• Nearly 7 in 10 Hispanic (67%) females in federal prison were mothers with minor children, compared to about 1 in 2 white (49%) and black (54%) females.

"• Among federal prisoners, about 3 in 5 black (64%) and Hispanic (64%) males and 3 in 10 white (34%) males were fathers with minor children.

"• The average age of a minor child among parents in state prison was 9 years old (table 4).

"• Among minor children of parents in state prison, 1% were younger than age 1, about 18% were ages 1 to 4, and 48% were age 10 or older.

"• The average age of a minor child among parents in federal prison was 10 years old.

"• An estimated 13% of minor children of federal prisoners were age 4 or younger, and 20% were ages 15 to 17."

"More schools and students are captured in the HYS [Washington Healthy Youth Survey] than MTF [Monitoring The Future Survey] (Table). The MTF included fewer low–socioeconomic status and nonwhite youth in the prelegalization vs postlegalization period.

"Estimates from the MTF show statistically nonsignificant change in the prevalence of cannabis use for 8th graders (from 6.2% [95% CI, 4.4%-8.7%] to 8.2% [95% CI, 6.3%-10.7%];P = .16), and a significant increase for 10th graders (from 16.2% [95% CI, 14.0%-18.6%] to 20.3% [95% CI, 16.9%-24.1%]; P = .02). In contrast, the HYS shows statistically significant declines in prevalence from 2010-2012 to 2014-2016 among both 8th graders (from 9.8% [95% CI, 9.1%-10.5%] to 7.3% [95% CI, 6.6%-8.0%]; P < .001) and 10th graders (from 19.8% [95%CI, 18.6%-21.0%] to 17.8% [95%CI, 16.7%-18.9%]; P = .01). Neither MTF nor HYS analysis showed changes among 12th graders (Figure). Findings from HYS comparisons to 2014 alone were of less magnitude but similar direction."

"Nationwide, 14.0% of students had taken prescription pain medicine (counting drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet) without a doctor’s prescription or differently than how a doctor told them to use it one or more times during their life (Supplementary Table 127)). The prevalence of having ever taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it was higher among Hispanic (15.1%) than black (12.3%) students and higher among Hispanic female (16.1%) than black female (12.5%) students. The prevalence of having ever taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it was higher among 11th-grade (15.4%) and 12th-grade (17.0%) than 9th-grade (10.9%) students, higher among 12th-grade (17.0%) than 10th-grade (12.8%) students, higher among 11th-grade female (16.4%) and 12th-grade female (16.2%) than 9th-grade female (12.1%) students, higher among 11th-grade male (14.3%) and 12th-grade male (17.7%) than 9th-grade male (9.7%) students, and higher among 12th-grade male (17.7%) than 10th-grade male (12.2%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, 12.9% of heterosexual students; 24.3% of gay, lesbian, and bisexual students; and 17.7% of not sure students had ever taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it (Supplementary Table 127). The prevalence of having ever taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it was higher among gay, lesbian, and bisexual (24.3%) and not sure (17.7%) than heterosexual (12.9%) students and higher among gay, lesbian, and bisexual (24.3%) than not sure (17.7%) students. Among female students, the prevalence was higher among lesbian and bisexual (23.8%) than heterosexual (12.9%) students. Among male students, the prevalence was higher among gay and bisexual (25.4%) than heterosexual (12.8%) and not sure (13.7%) students."

"Overall, an average of 2.5% of the students had used NPS at least once in the last 12 months, with the highest prevalence reported in Czechia, Latvia, Estonia, Poland and Monaco (4.0-4.9%) and the lowest prevalence reported in North Macedonia, Finland and Portugal ( 0.4-0.8%; Figure 10a). Generally, differences in NPS use between boys and girls were small; however, significantly more boys than girls reported the use of NPS in Cyprus, Georgia, Greece, Ireland, Montenegro, Norway and Serbia, and significantly more girls than boys reported the use of NPS in Latvia and Slovenia (Figure 10b).

"Among all students who had used NPS in the last 12 months, the majority (54%) reported use of herbal synthetic substances; 27% reported use of NPS in the form of powders or tablets, 13% reported the use of NPS in the form of liquids and 17% reported the use of NPS in other forms. Only a few countries reported higher rates of use of NPS in forms other than herbal smoking mixtures. In particular, powders/tablets were used by the majority of last-year NPS users in Finland (64%) and Norway (54%), liquids were reported by 36% of the users in the Netherlands, and the use of NPS in other forms was reported by half of the users in North Macedonia. Even though on average the differences between boys and girls in the reported appearance of NPS used in the last 12 months were low, in most individual countries noticeable gender differences were found. Focusing only on differences higher than 15 percentage points, with regard to herbal NPS, boys reported higher prevalence rates than girls in Romania, Georgia, Finland, Ireland and the Netherlands, while girls reported higher rates in Bulgaria, Ukraine, Slovakia and Lithuania; for powders/tablets, girls reported higher prevalence rates in many countries (Kosovo, Georgia, Slovakia, Serbia, Spain, Sweden, Ireland and Portugal), while a higher rate was found among boys in Cyprus; and higher prevalence rates were found for liquid forms of NPS among male users than female users in Portugal, Slovakia, Sweden, Lithuania and North Macedonia, with girls reporting higher rates in the Netherlands and Finland (see Additional Table 71a and b)."

"Generally, between 1995 and 2011, there was an increase in the lifetime prevalence of illicit drug use, most of which occurred between 1995 and 1999. Since 2011, the prevalence has started to decrease slowly. The lifetime prevalence of illicit drug use among boys and girls follows a parallel trend, with the rate among girls being about 5-6 percentage points lower than that among boys (Figure 21). As cannabis is the most widely used illicit drug, the trend for lifetime cannabis use is similar to the trend for any illicit drug use, with rates of the former being only slightly lower across all years (Table 14). The prevalence rate of lifetime cannabis use among boys peaked in 2003, remained stable until 2011 and started to decrease thereafter. The prevalence rate of lifetime cannabis use among girls peaked in 2003 and stabilised thereafter (Figure 22). The rate of current (last-30-day) use of cannabis reached its highest level in 2011, stabilising thereafter, with gender differences of 2-3 percentage points across all years (Table 14 and Figure 23).

"Lifetime use of illicit drugs other than cannabis rose to a peak in 2007 (Table 14). After 2007, the rate decreased slightly until 2015 and then stabilised in 2019. The same trend is observed among boys and girls, with a gender gap of 1-2 percentage points across all years (Figure 24)."

"Almost half of high school students (44 percent) know a student who sells drugs at their school. When asked what drugs are sold at their school:

• 91 percent said marijuana;
• 24 percent said prescription drugs;
• 9 percent said cocaine; and
• 7 percent said ecstasy."

"RESULTS: Positive, significant associations were found between parental incarceration and 8 of 16 health problems (depression, posttraumatic stress disorder, anxiety, cholesterol, asthma, migraines, HIV/AIDS, and fair/poor health) in adjusted logistic regression models. Those who reported paternal incarceration had increased odds of 8 mental and physical health problems, whereas those who reported maternal incarceration had increased odds of depression. For paternal incarceration, with the exception of HIV/AIDS, larger associations were found for mental health (odds ratios range 1.43–1.72) as compared with physical health (odds ratios range 1.26–1.31) problems. The association between paternal incarceration and HIV/AIDs should be interpreted with caution because of the low sample prevalence of HIV/AIDs."

"The teen brain is a work in progress, making it more vulnerable than the mature brain to the physical effects of drugs. The potential for developing substance abuse and dependence is substantially greater when an individual’s first exposure to alcohol, nicotine and illicit drugs occurs during adolescence than in adulthood."

"Overall, these data reveal that, while use of individual drugs (other than marijuana) may fluctuate widely, the proportion using any of them is much more stable. In other words, the proportion of students prone to using such drugs and willing to cross the normative barriers to such use changes more gradually. The usage rate for each individual drug, on the other hand, reflects many more rapidly changing determinants specific to that drug: how widely its psychoactive potential is recognized, how favorable the reports of its supposed benefits are, how risky its use is seen to be, how acceptable it is in the peer group, how accessible it is, and so on."

"In this nationwide study of commercially insured adolescents, LTOT [Long Term Opioid Therapy] was relatively uncommon. The estimated incidence of LTOT receipt was 3.0 per 1000 adolescents within 3 years of filling an initial opioid prescription. Although adolescents with a wide range of preexisting mental health conditions and treatments were modestly more likely than adolescents without those conditions or treatments to receive an initial opioid, the former had substantially higher rates of subsequent transitioning to LTOT. Associations were strongest for OUD [Opioid Use Disorder], OUD medications, nonbenzodiazepine hypnotics, and other SUDs. The associations were stronger sooner after first opioid receipt for OUD, as well as for anxiety and sleep disorders and their treatments, suggesting that adolescents with these conditions and treatments were more likely to quickly transition into LTOT."

"The increase in U.S. incarceration rates means that a sizable number of children experience parental incarceration. Between 5 million and 8 million children have had a resident parent (most often a father) incarcerated in jail, state prison, or federal prison, and this number excludes children with parents under other forms of correctional supervision such as probation or parole (Murphey & Cooper, 2015). A growing research literature conceptualizes parental incarceration as an adverse childhood experience (ACE) with considerable deleterious consequences for children's wellbeing (U.S. Department of Health and Human Services, 2015). Children exposed to parental incarceration, compared to their counterparts not exposed to parental incarceration, experience disadvantages across behavioral, educational, and health outcomes (for reviews, see Foster & Hagan, 2015; Johnson & Easterling, 2012; Murray, Farrington, & Sekol, 2012).

"Importantly, given social inequalities in exposure to criminal justice contact, many children of incarcerated parents are a demographically and socioeconomically disadvantaged group even prior to the experience of parental incarceration. For example, parental incarceration is more common among children of disadvantaged race/ethnic groups; about one-fourth (24%) of Black children and one-tenth (11%) of Hispanic children experience parental incarceration by age 17, compared to 4% of White children (Sykes & Pettit, 2014). Parental incarceration is also concentrated among children living in households with incomes below the poverty line, children of unmarried parents, and children residing in disadvantaged neighborhoods (Foster & Hagan, 2015; Wakefield & Wildeman, 2013)."

"A total of 11 articles met the inclusion criteria for the metaanalysis (Figure 1): 7 for depression^{10,16,34,38,44-46}; 3 for anxiety,^16,38,44 3 for suicidal ideation,^41,47,57 and 3 for suicide attempts.^10,54,57 To estimate the extent to which cannabis use
during adolescence was associated with increased odds of developing depression in young adulthood, we pooled results from 7 studies.^{10,16,34,38,44-46} The pooled OR [Odds Ratio] for depression during young adulthood among cannabis users compared with nonusers was 1.37 (95% CI, 1.16-1.62; I2 = 0%; Figure 2). Cannabis use during adolescence was associated with increased odds of developing anxiety in young adulthood when pooling 3 studies^16,38,44 (OR, 1.18; 95% CI, 0.84-1.67; I2 = 42.0%; Figure 2). Suicidal ideation is a symptom of depression, while suicide represents one of the most severe sequelae of mental illness. Results from 3 studies that had measured the association of cannabis use during adolescence with subsequent suicidal ideation within adolescence^41,57 and in young adulthood⁴⁷ were pooled with a resultant OR of 1.50 (95% CI, 1.11-2.03; I2: 0%; Figure 3). For the number of suicide attempt outcomes within adolescence^54,57 or during young adulthood,¹⁰ the results were pooled with a resultant OR of 3.46 (95% CI, 1.53-7.84; I2 = 61.3%; Figure 3)."

"This year we asked teens, 'Which is easiest to get: cigarettes, marijuana, beer or prescription drugs?' (prior to 2010, we asked, 'Which is easiest to buy?') Cigarettes remain at the top of the list, with 27 percent of teens saying cigarettes are easier to get than other drugs. Beer closely followed cigarettes as the easiest drug for teens to get. Marijuana is third, with 19 percent of teens reporting that it is easiest to get this year, compared to 22 percent last year. Compared to 2011, slightly more teens this year say prescription drugs are easier to get than other drugs (13 percent in 2012 vs. 10 percent in 2011)."

"At the end of the 2019–2020 school year, there were approximately 23,400 sworn school resource officers (SROs) in the United States (figure 1, table 1).¹ About 11,500 (49%) of these SROs were employed by local police departments, 7,600 (32%) were employed by sheriffs’ offices, and 4,400 (19%) were employed by school district police departments."

"In 2016 in the United States, 74% of all deaths among persons aged 10–24 years resulted from four causes: motor vehicle crashes (22%), other unintentional injuries (20%), suicide (17%), and homicide (15%) (1). Among persons aged 15–19 years, 209,809 births (2); 488,700 cases of chlamydia, gonorrhea, and syphilis (3); and 1,652 diagnoses of human immunodeficiency virus (HIV) (4) were reported. Among persons aged ≥25 years, 54% of all deaths in the United States resulted from cardiovascular disease (31%) and cancer (23%) (1). These leading causes of mortality, morbidity, and social problems (e.g., academic failure, poverty, and crime) among youth and adults in the United States are associated with six categories of priority health-related behaviors: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors that related to unintended pregnancy and sexually transmitted infections (STIs), including HIV infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. These behaviors, as well as obesity, overweight, and asthma, frequently are related, are established during childhood and adolescence, and extend into adulthood.

"Significant health disparities exist among demographic subgroups of youth defined by sex, race/ethnicity, and grade in school, and especially between sexual minority and nonsexual minority youth (5–7). More specifically, violence, human immunodeficiency virus (HIV) infection, STIs, and pregnancy occur more frequently among sexual minority youth than nonsexual minority youth. In addition, some sexual minority youth struggle with stigma, discrimination, family disapproval, and social rejection. However, although differences based on sex, race/ethnicity, and grade in school have been well documented, not enough is known about health-related behaviors that contribute to negative health outcomes among sexual minority youth (5,7)."

"Teen users are at significantly higher risk of developing an addictive disorder compared to adults, and the earlier they began using, the higher their risk. Nine out of 10 people who meet the clinical criteria for substance use disorders involving nicotine, alcohol or other drugs began smoking, drinking or using other drugs before they turned 18. People who begin using any addictive substance before age 15 are six and a half times as likely to develop a substance use disorder as those who delay use until age 21 or older (28.1 percent vs. 4.3 percent)."

“Teen marijuana users are approximately twice as likely as non-users to drop out of high school.²³⁴ One study found that, compared to students who did not use marijuana at all in the past year, those who used marijuana less than weekly were 2.6 times as likely to be school dropouts (5.8 percent vs. 2.2 percent) and those who used marijuana at least weekly were 5.8 times as likely to be school dropouts (12.8 percent vs. 2.2 percent).²³⁵ Students who use marijuana before age 15 are twice as likely as other students to report frequent truancy and three times as likely to leave school before age 16.²³⁶ One study found that, by their 40s, individuals who used marijuana in adolescence and young adulthood had more than a third of a year’s less educational attainment than non-users. The more frequent the marijuana use in this age group, the fewer the number of years of educational attainment achieved.”

"This term, which we hope can over time be employed as a keyword in the literature, is intended to foreground children under the age of majority and for whom child rights laws apply in harm reduction theory, policy and practice. Child-centred harm reduction draws attention to the specificities of childhood in harm reduction work. Existing theories of harm reduction may need adaptation to the sociology and psychology of childhood, including the interconnected relationship between parent and child, family-centred care, and attention to children’s rights (see Maynard et al., 2019). Some interventions may not be practical, effective or ethical for children (Watson et al., 2015). Research on existing harm reduction services that work with minors – including those that may not strictly be permitted to do so - may place those children or the service at risk. Issues of consent, identity, agency and maturity, as well as the child’s ‘best interests’ may challenge the assumptions and premises upon which ‘low threshold’ harm reduction services are delivered (Barrett, Petersson, & Turner, 2022). Different legal and human rights standards are engaged, from drug laws to family law to child rights. Child protection laws may require duties of reporting that affect harm reduction service provision and research (ibid). In some cases both parent and child can be legal minors, leading to further challenges and complications regarding assessments of best interests. National, regional and international policy frameworks may need renewed scrutiny through a child-centred harm reduction lens (see for example Barrett, 2015).

"The term is not perfect. For example, ‘child’ may conjure the image of only very young children, when the majority of drug use would involve older adolescents. Few seventeen year-olds would refer to themselves as children. However, those under the age of 18 are legal minors in most contexts, and are ‘children’ for the purposes of child rights. Other terms, such as ‘youth harm reduction’ reproduce the problem of age ranges noted above, while ‘adolescent harm reduction’ omits younger children. ‘Adolescence’ can also extend beyond the age of majority. ‘Paediatric harm reduction’ was considered, but implied an overly medical approach.

"The word ‘centred’ is critical. Our view of child-centred harm reduction extends from neonates to adolescents, with all of the challenges and differing capacities and relationships that arise at these stages of development. Centring the child is key and draws our attention also, for example, to dependent children in adult harm reduction work. We believe that ‘child-centred’ focuses on the specificities of childhood in harm reduction and captures a holistic, rights-based, and person-centred approach."

According to the Bureau of Justice Statistics, US jails in 2022 held 1,900 juveniles, of whom 1,600 were being held as adults.
In 2021, US jails held 2,000 juveniles, of whom 1,700 were being held as adults.
In 2012, US jails held 5,400 juveniles, of whom 4,600 were being held as adults.

"Note: Data are based on the inmate population confined on the last weekday in June."

"Of the 1,000,453 opioid recipients (81.7%) with at least 6 months of follow-up, 51.1% were female, and the median age was 17 years (interquartile range, 16-18 years). Among these adolescents, the estimated cumulative incidence of LTOT [Long Term Opioid Therapy] after first opioid receipt was 1.1 (95% CI, 1.1-1.2) per 1000 recipients within 1 year, 3.0 (95% CI, 2.8-3.1) per 1000 recipients within 3 years, 8.2 (95% CI, 7.8-8.6) per 1000 recipients within 6 years, and 16.1 (95% CI, 14.2-18.0) per 1000 recipients within 10 years. The prevalence of mental health conditions and treatments in this sample is shown in eTable 3 in the Supplement.

"All mental health conditions and treatments were associated with higher rates of transitioning from a first opioid prescription to long-term therapy. Table 2 provides the estimated incidence of LTOT among those with and without mental health conditions and treatments.Adjusted relative increases in the rate of LTOT ranged from a factor of 1.73 for ADHD [Attention-Deficit/Hyperactivity Disorder] (hazard ratio [HR], 1.73; 95% CI, 1.54-1.95) to approximately 4-fold for benzodiazepines (HR, 3.88; 95%CI, 3.39-4.45) and nonopioid SUDs [Substance Use Disorders] (HR, 4.02;95%CI, 3.48-4.65) to 6-fold for non benzodiazepine hypnotics (HR, 6.15; 95%CI, 5.01-7.55) and to nearly 9-fold for OUD [Opioid Use Disorder] (HR, 8.90; 95%CI, 5.85-13.54). In addition, relative to no condition, the number of condition types was also associated with higher LTOT rates (1 condition: HR, 2.21; 95% CI, 2.01-2.43; 2 or more conditions: HR, 4.01; 95% CI, 3.62-4.46).

"Given the strong associations for OUD, we explored other mental health factors and opioid receipt among those with preexisting OUD. These adolescents were more likely than
adolescents without OUD to have other mental health conditions and treatments (eTable 4 in the Supplement). For example, 76.1% of adolescents with OUD had other SUDs, 61.0% had depressive disorders, and 52.6% had received an SSRI [Selective Serotonin Reuptake Inhibitor]. During follow-up, those with preexisting OUD received opioid drugs similar to those received by adolescents without OUD, although the former were more likely to receive certain opioids (eg, oxycodone and tramadol; eTable 5 in the Supplement). Of those with preexisting OUD, 15.5% filled a prescription for OUD medication treatment during follow-up."

"About 83% of all sworn SROs were male, and 17% were female (table 2). In both local police departments and sheriffs’ offices, 84% of SROs were male and 16% were female. In school district police departments, 81% of SROs were male and 19% were female. There were no statistically significant differences by agency type in the percentages of male SROs or female SROs.

"Of all sworn SROs, 60% were white males, while black males and white females each accounted for about 10%. Hispanic males made up 8% of SROs, and males of another race made up about 5%. About 4% of sworn SROs were black females, 2% were Hispanic females, and less than 1% were females of another race.

"A larger portion of sworn SROs in local police departments (63%) and sheriffs’ offices (68%) than in school district police departments (38%) were white males. Black males made up a larger percentage of SROs employed by school district police departments (18%) than by sheriffs’ offices (9%) or local police departments (8%). School district police departments (19%) employed a larger percentage of Hispanic male SROs than local police departments (7%) or sheriffs’ offices (3%)."

"Compared to teens who have five to seven family dinners per week, those who have fewer than three family dinners per week are twice as likely to say they expect to try drugs (including marijuana and prescription drugs without a prescription to get high) in the future (17 percent vs. 8 percent)."

"Every year teens tell us that tobacco, alcohol and other drugs are the biggest problem facing teens their age. This year, 26 percent of teens surveyed say that alcohol, drugs and tobacco are the most important issue teens face, followed by social pressures [18%] and academic pressures [11%]."

"Children exposed to parental incarceration were more likely to have other ACEs than children not exposed to parental incarceration. For example, only 14.3% of children exposed to parental incarceration had no other ACEs, compared to 72.2% of children not exposed to parental incarceration. Further, among children exposed to parental incarceration, about 28.9% experienced one other ACE (compared to 19.4% of children not exposed to parental incarceration), 21.2% experienced two other ACEs (compared to 5.5%), 16.4% experienced three other ACEs (compared to 1.8%), and 19.3% experienced four or more other ACEs (compared to 1.2%).

"Table 2 presents descriptive statistics of ACEs for two groups of children: those who experienced parental incarceration and those who did not experience parental incarceration. Children exposed to parental incarceration had more ACEs than those not exposed to parental incarceration (2.06 compared to 0.41, p < 0.001). Children exposed to parental incarceration were also more likely to report any ACE (85.7% compared to 27.8%, p < 0.001). Children exposed to parental incarceration were nine times more likely to experience household member abuse (31.9% compared to 3.4%, p < 0.001) and violence exposure (20.3% compared to 2.3%, p < 0.001). They were eight times more likely to experience household member substance problems (45.5% compared to 5.8%, p < 0.001); five times more likely to experience parental death (11.8% compared to 2.5%, p < 0.001); and four times more likely to experience household member mental illness (24.1% compared to 6.4%, p < 0.001) and parental divorce or separation (72.7% compared to 20.5%, p < 0.001)."

"It has long been postulated that ongoing neurodevelopmental processes during adolescence may impart heightened vulnerability to cannabis exposure and increase the likelihood of long-term associations with cognition and behavior. Many animal studies have reported enduring effects of adolescent exposure to tetrahydrocannabinol (THC), the primary psychoactive substance in cannabis. Specifically, adolescent exposure to THC has been shown to decrease social behavior in adult rats^46,47 as well as alter motivational processes.⁴⁸ Rodent and primate studies have also demonstrated that adolescent exposure to THC results in working memory deficits in adulthood.^49-52 Several rodent studies have also found that adolescent THC exposure results in lasting alterations in glutamatergic and γ-aminobutyric acidergic functioning.^53,54 In humans, adolescent-onset cannabis users exhibit greater use-associated problems in adulthood relative to late-onset cannabis users.^55,56 Findings from the present study may help to elucidate heightened vulnerability to the effects of cannabis use among adolescents. We found that the statistical map of age-related cortical change was significantly correlated with statistical maps of the time × cannabis interaction on cortical thickness as well as the main association of cannabis use with cortical thickness at 5-year followup. Taken together, these results suggest that, on average, cannabis use tended to qualify cortical thickness change within areas already undergoing the greatest degree of age-related change (from baseline to 5-year follow-up). This finding provides support for the association of cannabis use with ongoing maturational processes in the brain and a possible explanation for the heightened vulnerability to the cognitive outcomes of cannabis use among adolescents. More important, our imaging findings are consistent with recent animal research on adolescent THC exposure and prefrontal cortical maturation. Miller et al¹⁵ examined the association of adolescent THC exposure with prefrontal cortical maturation using a rat model. Researchers injected male rats with THC during the period of their adolescence, spanning 4 to 7 weeks of age. They found that adolescent THC exposure resulted in distinct proximate and long-term alterations of dendritic architecture. Specifically, THC exposure disrupted normal neurodevelopmental processes by inducing premature pruning of dendritic spines and atrophy of dendritic arbors in early adulthood. We hypothesize that the MR imaging (MRI)–assessed cannabis-related thinning revealed in our human study is underpinned by the same neurobiological phenomenon."

"Several limitations of the present study should also be addressed. The PET data used in this study were collected on a separate sample of young adults, not the 799 youths who underwent longitudinal neuroimaging. Given the invasive nature of PET imaging and its associated risks, it is not ethical to collect PET data on minors. We cannot state definitively that, in our sample of 799 participants, the areas exhibiting cannabis-related thinning in longitudinal MRI analysis were, in fact, high in CB1 receptor availability. Our present findings are also limited by the self-report nature of our cannabis use measure. As with any self-report measure, it is possible that participants were not honest regarding their cannabis use or that their estimates of past cannabis use were inaccurate. We also did not have information pertaining to the types of cannabis products used (eg, cannabis oil concentrates and other formulations). As in other longitudinal MRI studies, there is uncertainty with regard to the exact neurobiological mechanisms associated with MRI-assessed cortical thinning. Research suggests that MRI-assessed, age-related cortical thinning may reflect increased myelination of lower cortical layers as opposed to synaptic pruning and/or neuronal cell loss.⁵⁷ Natu et al⁵⁷ found good correspondence between MRI-assessed cortical thickness and histologic measurements of cortical thickness among young adults. This latter finding is critical given that we detected cannabis-related differences in cortical thickness at age 19 years and not at 14 years, suggesting that our MRI-assessed cortical thickness findings are associated with reduced cortical gray matter rather than increased myelination. The present study focused on cortical thickness development and did not examine potential cannabis-related outcomes within subcortical structures. Future studies may benefit from conducting similar analyses on subcortical regions, particularly those rich in CB1 receptors. Most important, given the observational nature of the present study, it is possible that the apparent association between cortical thinning and cannabis use reflects preexisting trajectories of brain maturation that were not caused by cannabis use. We cannot rule out the possibility that preexisting cognitive and/or behavioral differences are associated with neurodevelopmental trajectories from adolescence to early adulthood and that cannabis use is not causally related to cerebral cortical thickness development."

"Abuse of prescription medicine [by teens] remains high, but there are signs that it may be plateauing. Close to one in five teens (17 percent) say they have used a prescription medicine at least once in their lifetime to get high or change their mood. This is slightly, although not significantly, down from 22 percent in 2010 and from 20 percent in 2009. Use of prescription pain medicines, specifically Vicodin or OxyContin, is trending downward. One out of ten teens reports using pain medication to get high in the past year and six percent say they used in the past 30 days – down significantly from 2009 levels."

"About 83% of sworn SROs had conducted video surveillance of schools in the past 30 days (table 7). About half of all SROs had conducted security audits or assessments of school campuses (51%) or monitored social media (47%). About 45% of SROs had participated in crisis preparedness training or on a threat assessment team.

"A lower percentage of sworn SROs in local police departments (78%) than in sheriffs’ offices (85%) or school district police departments (92%) had conducted video surveillance. A higher percentage of SROs in local police departments (49%) or sheriffs’ offices (51%) had monitored social media than in school district police departments (37%). There were no statistically significant differences by agency type in the percentages of SROs who had participated in crisis preparedness training or on a threat assessment team."

"Slightly less than half of all sworn SROs reported that they had confiscated drugs (45%) within the past 30 days (figure 6). Nearly 4 in 10 SROs had made an arrest (39%) or issued a criminal citation (37%) in the past 30 days. About 23% of SROs had confiscated a weapon.

"Sworn SROs in school district police departments were the most likely to report confiscating drugs (60%), followed by SROs in local police departments (47%). A higher percentage of SROs in local police departments (41%) than in sheriffs’ offices (35%) or school district police departments (29%) had issued criminal citations. A smaller portion of SROs in sheriffs’ offices (32%) than in local police departments (41%) or school district police departments (45%) reported that they had made an arrest in the past 30 days."

"Alcohol and marijuana are the two most commonly used substances by teenagers to get high, and a question that is often asked is to what extent does change in one lead to a change in the other. If the substances co-vary negatively (an increase in one is accompanied by a decrease in the other) they are said to be substitutes; if they co-vary positively, they are said to be complements.

"Interestingly, the answer may differ by historical era. Before 2007 patterns of use for the two substances suggested they acted as complements. When marijuana use increased in the late 1970s, so too did alcohol use. Between 1979 and 1992 marijuana use declined and a parallel decline took place in annual, monthly, and daily alcohol use, as well as in binge drinking among 12th graders. As marijuana use increased again in the 1990s, alcohol use again increased with it, although not as sharply. In sum, before 2007 there was little evidence from MTF to support what we have termed “the displacement hypothesis,” which asserts that an increase in marijuana use will lead to a decline in alcohol use, or vice versa.8

"However, since 2007 a new trend has emerged that would be consistent with the “displacement” hypothesis. From 2007 through 2019 alcohol use declined markedly, reaching historic lows in the life of the study. Meanwhile, for most of this time period marijuana use has stayed steady or increased for all age groups. For the first time trends in alcohol and marijuana use are substantially diverging, suggesting that the historical relationship between these two drugs may have changed."

"During the 12 months before the survey, 31.5% of students nationwide had felt so sad or hopeless almost every day for 2 or more weeks in a row that they stopped doing some usual activities (Supplementary Table 42). The prevalence of having felt sad or hopeless was higher among female (41.1%) than male (21.4%) students; higher among white female (38.2%), black female (40.7%), and Hispanic female (46.8%) than white male (21.4%), black male (17.3%), and Hispanic male (21.2%) students, respectively; and higher among 9th-grade female (40.0%), 10th-grade female (43.1%), 11th-grade female (43.6%), and 12th-grade female (37.5%) than 9th-grade male (19.5%), 10th-grade male (21.5%), 11th-grade male (20.9%), and 12th-grade male (24.1%) students, respectively. The prevalence of having felt sad or hopeless was higher among Hispanic (33.7%) than white (30.2%) and black (29.2%) students and higher among Hispanic female (46.8%) than white female (38.2%) students. The prevalence of having felt sad or hopeless was higher among 10th-grade female (43.1%) and 11th-grade female (43.6%) than 12th-grade female (37.5%) students and higher among 12th-grade male (24.1%) than 9th-grade male (19.5%) students.

"Analyses based on the question ascertaining sexual identity indicated that nationwide, 27.5% of heterosexual students; 63.0% of gay, lesbian, and bisexual students; and 46.4% of not sure students had felt sad or hopeless (Supplementary Table 42). The prevalence of having felt sad or hopeless was higher among gay, lesbian, and bisexual (63.0%) and not sure (46.4%) than heterosexual (27.5%) students and higher among gay, lesbian, and bisexual (63.0%) than not sure (46.4%) students. Among female students, the prevalence was higher among lesbian and bisexual (68.8%) and not sure (51.9%) than heterosexual (36.8%) students and higher among lesbian and bisexual (68.8%) than not sure (51.9%) students. Among male students, the prevalence was higher among gay and bisexual (45.5%) and not sure (36.4%) than heterosexual (19.5%) students. The prevalence also was higher among heterosexual female (36.8%) than heterosexual male (19.5%) students, higher among lesbian and bisexual female (68.8%) than gay and bisexual male (45.5%) students, and higher among not sure female (51.9%) than not sure male (36.4%) students."

"Depressive disorders have an association with alcohol abuse or dependence and cannabis dependence. There are also reciprocal effects of suicidality and substance use. Mood disorders (including bipolar disorders — hypomania and mania) predict increased rates for cannabis use and cannabis use disorder. For anxiety disorders, results were variable."

"Younger teens (ages 12 to 13 and 14 to 15) are more likely to say that they can get prescription drugs in an hour, and within a day, compared to marijuana, while older teens (16- to 17) are more likely to be able to get to marijuana within a day."

"The prevalence of any PI [Parental Incarceration] was 12.5% with the 95% confidence interval (CI) of 11.3% to 13.8%. The distribution of incarceration status by category was: neither parent (87.5%, 95% CI: 86.2%–88.7%), father only (9.9%, 95% CI: 8.9%–10.9%), mother only (1.7%, 95% CI: 1.4%–2.0%), and both parents (0.9%, 95% CI: 0.7%–1.2%). A significant association was found between race and PI. Black and Hispanic individuals had the highest prevalence of PI, 20.6% and 14.8%, compared with 11.9% for white individuals and 11.6% for those classified as other. Pairwise comparison indicated the black and white prevalence rates were significantly different."

^{Note: Regarding study sample size: "The current study used data from the National Longitudinal Study of Adolescent Health (Add Health), a 4-wave longitudinal study following a nationally representative probability sample of adolescents in grades 7 through 12 in the 1994–1995 school year.46 The first 3 waves of Add Health data were collected from April to December 1995, from April to August 1996, and from August 2001 to April 2002. The fourth wave of data was collected in 2007 and 2008. The full sample for Wave 4 included 15 701 or 80.3% of the eligible participants from Wave 1. The response rates for Waves 1, 2, 3, and 4 were 79.0%, 88.6%, 77.4%, and 80.3%, respectively. The mean ages of participants during the 4 waves of data collection were 15.7 years, 16.2 years, 22.0 years, and 28.8 years, respectively.}

"The current study was based on 14,800 participants who were interviewed during Wave 1 and Wave 4 and have a sampling weight. Of the 15,701 participants who participated in both Wave 1 and Wave 4 interviews, 14,800 participants have a sampling weight at Wave 4 interview that could be used to compute population estimates. For data analysis, data describing participants’ sociodemographic characteristics from Wave 1 of the Add Health study were combined with Wave 4 self-reported health outcomes and PI history."

“High school students in CASA’s survey who report having ever used marijuana are more likely than students who never used marijuana to report that they feel alone or isolated (26.7 percent vs. 19.9 percent), that they often feel very sad or depressed (27.9 percent vs. 14.0 percent) and that they think they will develop depression during their lifetime (41.0 percent vs. 25.4 percent).⁷”

"It is important to note that the negative consequences of prescription medicine abuse remain extensive and troubling. Emergency room visits as a result of prescription medications increased 45 percent between 2004 and 2009 among children under 20 years of age¹. Admissions to treatment for prescription medicine abuse among adolescents have also increased and deaths caused by drug overdoses, led by prescription medicines, now outnumber traffic fatalities in the United States²."

"Teens who have high-quality relationships with Mom and Dad are less likely to use drugs, drink or smoke.
"Compared to teens who say they have an excellent relationship with Dad,* teens who have a less than very good relationship with their father are:
• Almost four times likelier to have used marijuana (23 percent vs. 6 percent);
• Twice as likely to have used alcohol (35 percent vs. 16 percent); and
• Two and a half times as likely to have used tobacco (15 percent vs. 6 percent).
"Compared to teens who say they have an excellent relationship with Mom,† teens who have a less than very good relationship with their mother are:
• Almost three times likelier to have used marijuana (26 percent vs. 9 percent);
• Two and a half times as likely to have used alcohol (45 percent vs.18 percent); and
• Two and a half times likelier to have used tobacco (16 percent vs. 6 percent)."

"In conclusion, our study of self-reported marijuana use by adolescents in states with a medical marijuana policy compared with a sample of geographically similar states without a policy does not demonstrate increases in marijuana use among high school students that may be attributed to the policies."

"• In 2013, the rate of current illicit drug use among youths aged 12 to 17 who smoked cigarettes in the past month was approximately 9 times the rate among youths who did not smoke cigarettes in the past month (53.9 vs. 6.1 percent). Also, the rate of current marijuana use in 2013 among youths aged 12 to 17 who smoked cigarettes in the past month was about 11 times the rate among youths who did not smoke cigarettes (49.5 vs. 4.6 percent).

"• In 2013, the rate of current illicit drug use was associated with the level of past month alcohol use. Among youths aged 12 to 17 who were heavy drinkers (i.e., consumed five or more drinks on the same occasion on each of 5 or more days in the past 30 days), 62.3 percent were current illicit drug users and 57.9 percent were current marijuana users. These rates were higher than the rates among youths who were not current alcohol users (4.9 percent for current illicit drug use and 3.3 percent for current marijuana use). Additionally, among youths aged 12 to 17 who were binge but not heavy alcohol users (i.e., consumed five or more drinks on the same occasion on 1 to 4 days in the past 30 days), 46.6 percent were current illicit drug users and 43.2 percent were current marijuana users (with the marijuana use rate being higher than the 2012 rate of 37.8 percent).

"• In 2013, the rate of current illicit drug use among youths aged 12 to 17 who both smoked cigarettes and drank alcohol in the past month was approximately 16 times the rate among those who neither smoked cigarettes nor drank alcohol in the past month (64.5 vs. 3.9 percent). Additionally, the rate of current marijuana use among youths aged 12 to 17 who both smoked cigarettes and drank alcohol in the past month was about 25 times the rate among those who neither smoked cigarettes nor drank alcohol in the past month (59.7 vs. 2.4 percent)."

"Compared to teens who have never seen pictures on Facebook, MySpace or another social networking site of kids getting drunk, passed out, or using drugs, teens who have seen such pictures are:

• Four times likelier to have used marijuana (25 percent vs. 6 percent);
• More than three times likelier to have used alcohol (43 percent vs. 13 percent); and
• Almost three times likelier to have used tobacco (16 percent vs. 6 percent)."

"In 2018, juvenile justice administrators reported 2,467 allegations of sexual victimization in state juvenile systems and locally or privately operated juvenile facilities (figure 1). Of those allegations, 321 were substantiated based on a follow-up investigation. Sexual victimizations include youth-on-youth nonconsensual sexual acts and abusive sexual contact, and staff sexual misconduct and sexual harassment.1 The number of sexual victimization allegations rose 89% from 2013 to 2018, while the number of substantiated incidents grew 44%. The overall rate of reported allegations increased from 21.7 per 1,000 youth in juvenile facilities in 2013 to 54.1 per 1,000 in 2018. Youth made a total of 12,060 allegations from 2013 to 2018, more than half (52%) of which were allegedly perpetrated by staff. About 8% of these staff-on-youth allegations were substantiated, compared to 23% of youth-on-youth allegations."

"Allegations of sexual victimization in all types of juvenile facilities increased by 995 (76%) between 2013 and 2016 (table 1). During that period, allegations increased by 477 (66%) in state juvenile systems and by 518 (88%) in locally and privately operated facilities. These increases can be partly attributed to juvenile justice authorities’ response to the 2012 release of the National Standards to Prevent, Detect, and Respond to Prison Rape.⁴ From 2016 to 2018, the number of allegations generally remained stable across juvenile facilities, though they increased by 177 (15%) in state juvenile systems."

"The overall rate of allegations in juvenile facilities increased from 2013 to 2018. From 2013 to 2016, state juvenile systems (up 117%) and local and private facilities (up 115%) saw their rates more than double. From 2016 to 2018, there was a further 32% increase in the rate in state systems (from 81.3 to 107 allegations per 1,000), while the rate in local and private facilities remained stable (30.7 per 1,000 youth in 2016 and 33.4 per 1,000 in 2018). From 2013 to 2018, state juvenile systems accounted for 52% to 62% of all reported allegations but about 30% of all youth held by juvenile justice authorities (not shown in tables). As a result, the rate of allegations has been 2.6 to 4.2 times as high in state systems as in local and private juvenile facilities.⁵"

"• Forty-five percent of high school students say that there are gangs or students who consider themselves to be part of a gang in their school.
"• Thirty-five percent of middle school students say that there are gangs or students who consider themselves to be part of a gang in their school.
"Compared to teens in schools without gangs, those in schools that have gangs are nearly twice as likely to report that their school is drug infected, meaning drugs are used, kept or sold on school grounds (30 percent vs. 58 percent).
"A quarter of public school students (27 percent) say that their school is both drug infected and has gangs."

"Patients aged 20 or younger accounted for 18.8 percent (922,953 visits) of all drug-related ED visits in 2010. About one half (45.3 percent, or 417,856 visits) of these visits involved drug misuse or abuse, representing a rate of 476.1 ED visits per 100,000 population aged 20 or younger."

“Each year that the onset of substance use is delayed until the mid-20s - about the time when the human brain is more fully developed¹⁰ — the risk of developing a substance use disorder is reduced.¹¹ Among people who used any of these substances before age 18, one in four have a substance disorder, compared with one in 25 who started to smoke, drink or use other drugs at age 21 or later.”¹²

"In 2011, there were 719,000 persons aged 12 or older who had used inhalants for the first time within the past 12 months, which was lower than the numbers in prior years from 2002 to 2005 (ranging from 849,000 to 877,000). An estimated 67.1 percent of past year initiates of inhalants in 2011 were under age 18 when they first used. The average age at first use among recent initiates aged 12 to 49 was similar in 2010 and 2011 (16.3 and 16.4 years, respectively)."

"Inhalants rank second among the illicit drugs in lifetime prevalence for 8th graders (9.5%) and third for 10th graders (6.8%); but they rank eighth for 12th graders (5.3%). Inhalants also rank second-highest in 30-day prevalence among the illicit drugs for 8th graders (2.1%) and fourth (1.1%) among 10th graders, but they rank lower for 12th graders (0.9%). Note that the youngest respondents report the highest levels of use; this is the only class of drugs for which current use declines with age during adolescence.³"

^3: "The results also indicate declining lifetime inhalant prevalence at higher grades, which could be due to various factors. There might be lower lifetime prevalence at older ages because the eventual school dropout segment is included only in the lower grades. If those who will become dropouts are unusually likely to use inhalants, lifetime use rates could decline with grade level. That would lead to a relatively stable difference between the grades in lifetime use (because dropout rates have been fairly stable in recent years); however, the degree of difference has changed some over time, with larger differences emerging in the mid-1990s. Another possible factor is changing validity of reporting with age; but in order to account for the trend data, one would have to hypothesize that this tendency became stronger in the 1990s, and we have no reason to believe that it did. Cohort differences may be a factor, but cannot completely explain the large changes in lifetime prevalence. It seems likely that all of these factors contribute to the differences observed in the retrospective reporting by different ages, and possibly some additional factors as well."

"• The percentage of adolescents (i.e., youths aged 12 to 17) who used inhalants in the past year was lower in 2007 (3.9 percent) than in 2003, 2004, and 2005 (4.5, 4.6, and 4.5 percent, respectively)
"• Among adolescents who used inhalants for the first time in the past year (i.e., past year initiates), the rate of use of nitrous oxide or “whippits” declined between 2002 and 2007 among both genders (males: 40.2 to 20.2 percent; females: 22.3 to 12.2 percent)
"• In 2007, 17.2 percent of adolescents who initiated illicit drug use during the past year indicated that inhalants were the first drug that they used; this rate remained relatively stable between 2002 and 2007
^{(Note: "Inhalants" are defined as: "Aerosol sprays other than spray paint include products such as aerosol air fresheners, aerosol spray, and aerosol cleaning products (e.g., dusting sprays, furniture polish). The aerosol propellants in these products are commonly chlorofluorocarbons. By contrast, nitrous oxide is used as a propellant for whipped cream and is available in 2-inch tapered cylinders called “whippits” that are used to pressurize home whipped-cream charging bottles.")}

"Paternal incarceration, however, was found associated with a greater number of health outcomes than maternal incarceration. Also, paternal incarceration was found to be associated with both physical and mental health problems, whereas maternal incarceration was found associated only with poor mental health.
"For paternal incarceration, with the exception of HIV/AIDS, larger associations were found for mental health as compared with physical health outcomes. Caution should be taken in understanding the significance of the finding related to HIV/AIDS, given its low overall sample prevalence and wide CI. If this is a true association, it may be related to paternal HIV/AIDS status and other risk factors related to father absence. Given the high correlation between HIV/AIDS and incarceration, increased odds of HIV/AIDS in offspring could come from perinatal transmission. However, social factors may also explain this relationship."

"• In 2019 for the second time in the history of the survey a majority of 12th grade students – 51% – did not favor legally prohibiting marijuana use in public places (the first time was in 2018). The percentage favoring legal prohibitions against use in private was also near a historic low at 21% in 2019, down from 82% in 1990.

"• The majority of 12th graders agree that people should be prohibited by law from using illicit drugs other than marijuana in public. (The questions specified people age 18 or older; presumably proportions would be even higher for those under 18.) For example, in 2019 the percentages agreeing to prohibition are 62% for amphetamines or sedatives (barbiturates), 69% for LSD, and 77% for heroin. Even use in private is opposed by substantial proportions; for example, 40% believe that nonmedical use in private of amphetamines or sedatives (barbiturates) should be illegal, while 46% believe the same for LSD, and 68% believe it about heroin use.

"• In 2019, 36% of 12th graders believe that cigarette smoking in “certain specified public places” should be prohibited by law. Were the question more specific as to the types of public places in which smoking might be prohibited (e.g., restaurants or hospitals), quite different results might have emerged.

"• Less than half (41%) of 12th graders in 2019 think that getting drunk in public should be prohibited.

"• For all drugs included in the question, fewer 12th graders believe that use in private settings should be illegal, as compared with use in public settings. This is particularly true for getting drunk in private (which only 17% think should be illegal vs. 41% for getting drunk in public) and for smoking marijuana in private (which only 21% think should be illegal vs. 49% for smoking marijuana in public places)."

"As shown in Table 2, bivariate analyses indicate PI [Parental Incarceration] was significantly associated with 8 of the 16 health conditions (heart disease, asthma, migraines, depression, anxiety, posttraumatic stress disorder [PTSD], HIV/AIDS, and fair/poor health). With the exception of heart disease and HIV/AIDS, individuals who reported neither parent had an incarceration history had the lowest prevalence rates of these 8 health conditions. Individuals who reported father incarceration only had the highest prevalence rates of 3 of the 8 health conditions (heart disease, HIV/AIDS, and fair/poor health); whereas individuals who reported mother incarceration only were highest on 2 conditions (depression and anxiety) and individuals who reported incarceration of both parents were highest on 3 conditions (asthma, migraine, and PTSD)."

"• Table 8-8 lists the proportions of 12th graders in 2019 who favor various legal consequences for marijuana use. The proportion who believe it should be entirely legal was 51%, the highest level recorded by the survey. As the percentage favoring legality increased, the percentage believing marijuana use should be a crime decreased and in 2019 was 9%, the lowest level recorded by the survey, having fallen from a peak of 53% in 1990.

"• Asked whether they thought it should be legal to sell marijuana if it were legal to use it, about two in three (67%) said “yes,” matching the historic high of 67% set in 2017. However, about 87% of those answering “yes” (58% of all respondents) would permit sale only to adults. A small minority (9%) favored the sale to anyone, regardless of age, while 20% said that sale should not be legal even if use were made legal, and 13% said they “don’t know.” Thus, while the majority now subscribe to the idea of legal sale, if use is allowed, the great majority agree with the notion that sale to underage people should not be legal.

"• Most 12th graders felt that they would be little affected personally by the legalization of either the sale or the use of marijuana. Forty-three percent of the 2019 respondents said that they would not use the drug even if it were legal to buy and use, while others indicated that they would use it about as often as they do now (17%) or less often (1%). Only 10% said they would use it more often than they do at present, while 17% thought they would try it. Another 12% said they did not know how their behavior would be affected if marijuana were legalized. Still, this amounts to 27% of all 12th graders, or about one in four, who thought that they would try marijuana, or that their use would increase, if marijuana were legalized.

"• A study of the effects of decriminalization by several states during the late 1970s, based on MTF data, found no evidence of any impact on the use of marijuana among young people, nor on attitudes and beliefs concerning its use.18 However, it should be noted that decriminalization falls well short of the full legalization posited in the questions here. Moreover, the situation today is very different from the one in the late 1970s, with more peer disapproval and more rigorous enforcement of drug laws, at least until recently. Some more recent studies suggest that there might be an impact of decriminalization, because “youths living in decriminalized states are significantly more likely to report currently using marijuana.”¹⁹ One study using MTF data shows that prevalence of marijuana use among 12th grade Californian students significantly increased in the two years after decriminalization went into effect in 2011, and youth attitudes also became significantly more permissive.²⁰ As more states approve full legalization of recreational use for adults (as has occurred in California, Illinois, Massachusetts, Michigan, Nevada, Maine, Colorado, Washington, Oregon, Alaska, Vermont, and Washington, DC), it is possible that attitudes about, and use of, marijuana will change. Declines in perceived risk and disapproval of marijuana would seem the most likely attitudinal changes, and such changes may well lead to increased use among youth."

"Approximately 12.3% of the respondents -- high school seniors in the United States -- reported lifetime nonmedical use of prescription opioids and 8.0% reported past-year nonmedical use. Table 1 shows the prevalence of motives for nonmedical use of prescription opioids among high school seniors in the United States. The leading motives included 'to relax or relieve tension' (56.4%), 'to feel good or get high' (53.5%), 'to experiment-see what it's like' (52.4%), 'to relieve physical pain' (44.8%), and 'to have a good time with friends' (29.5%).

"The lifetime medical use of prescription opioids was reported by approximately 14.0% of those who did not engage in past-year nonmedical use of prescription opioids, 76.1% of nonmedical users of prescription opioids motivated only by pain relief, 71.4% of those motivated by pain relief and other motives, and 46.7% of those who reported non-pain relief motives only (p < 0.001). Among past-year nonmedical users of prescription opioids, approximately 56.5% of those motivated only by pain relief as compared to 23.1% of those who reported pain relief and other motives, and 14.2% of those who reported only non-pain relief motives had initiated medical use of prescription opioids before nonmedical use of prescription opioids. In contrast, approximately 19.6% of those motivated only by pain relief as compared to 48.3% of those who reported pain relief and other motives, and 32.5% of those who reported only non-pain relief motives initiated nonmedical use of prescription opioids before medical use of prescription opioids."

"It is important to note that, contrary to alcohol, benzodiazepines and nicotine, opioids do not have teratogenic potential (3). Thus, special attention needs to be paid to dependence and abuse of legal substances and prescription drugs that can have severe consequences for the foetus and newborn, such as foetal developmental disorders or sudden infant death syndrome (Fetal Alcohol Spectrum Disorders Center for Excellence, 2013; McDonnell-Naughton et al., 2012)."

"Overall, supply reduction—that is, reducing the availability of drugs—does not appear to have played as major a role as many had assumed in four of the five most important downturns in illicit drug use that have occurred to date, namely, those for marijuana, cocaine, crack, and ecstasy (see, for example, Figures 8-4, 8-5, and 8-6). The case of cocaine is particularly striking, as perceived availability actually rose during much of the period of downturn in use that began in the mid- 1980s. (These data are corroborated by data from the Drug Enforcement Administration on trends in the price and purity of cocaine on the streets.⁸) For marijuana, perceived availability has remained very high for 12th graders since 1976, while use dropped substantially from 1979 through 1992 and has fluctuated considerably thereafter. Perceived availability for ecstasy did increase in parallel with increasing use in the 1990s, but the decline phase for use appears to have been driven much more by changing beliefs about the dangers of ecstasy than by any sharp downturn in availability. Similarly, amphetamine use declined appreciably from 1981 to 1992, with only a modest corresponding change in perceived availability. Finally, until 1995, heroin use had not risen among 12th graders even though availability had increased substantially.

"• What did change dramatically were young peoples’ beliefs about the dangers of using marijuana, cocaine, crack, and ecstasy. We believe that increases in perceived risk led to a decrease in use directly through their impact on young people’s demand for these drugs and indirectly through their impact on personal disapproval and, subsequently, peer norms. Because the perceived risk of amphetamine use was changing little when amphetamine use was declining substantially (1981–1986), other factors must have helped to account for the decline in demand for that class of drugs—quite conceivably some displacement by cocaine. Because three classes of drugs (marijuana, cocaine, and amphetamines) have shown different patterns of change, it is highly unlikely that a general factor (e.g., a broad shift in attitudes about drug use) can explain their various trends.

"• The increase in marijuana use in the 1990s among 12th graders added more compelling evidence to this interpretation. It was both preceded and accompanied by a decrease in perceived risk. (Between 1991 and 1997, the perceived risk of regular marijuana use declined 21 percentage points.) Perceived peer disapproval dropped sharply from 1993 through 1997, after perceived risk began to change, consistent with our interpretation that perceived risk can be an important determinant of disapproval as well as of use. Perceived availability remained fairly constant from 1991 to 1993 and then increased seven percentage points through 1998.⁹

"• We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion, such as snorting and smoking. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self-reported heroin users in recent years are using by means other than injection, lends credibility to this interpretation. The dramatic decline in LSD use in the early to mid 2000s is also not explainable by means of concurrent changes in perceived risk or disapproval; but availability did decline sharply during this period and very likely played a key role in reducing the use of that drug.

"We should also note that other factors, such as price, could play an important role for some drugs. Analyses of MTF data have shown, for example, that price probably played an important role in the decline of marijuana use in the 1980s, and in changes in cigarette use in the 1990s.^10,11 However, price does not appear to have the same influence in all periods for all drugs, as the dramatic reduction in cocaine prevalence during the late 1980s took place at the same time that the price of cocaine decreased,¹² contrary to the supply/demand model."

"Marijuana, the most widely used of the illicit drugs, did not show any significant change in annual prevalence this year in any of the three grades, nor in the three grades combined. After rising for several years, the annual prevalence of marijuana has more or less leveled out since about 2010.

"This year, 12 percent of 8th ­graders, 25 percent of 10th ­graders and 35 percent of 12th ­graders reported using marijuana at least once in the prior 12 months. Of more importance, perhaps, is their daily or near-­daily marijuana use (defined as smoking marijuana on 20 or more occasions in the past 30 days). These rates stand at 1.1 percent, 3.0 percent and 6.0 percent in 8th, 10th and 12th grades, respectively.

"In other words, one in every 16 or 17 high school seniors is smoking marijuana daily or near daily. These rates have changed rather little since 2010, but are from three-­to-­six times higher than they were at their low point in 1991.

"'The proportion of our young people smoking marijuana this frequently remains a matter of concern,' Johnston said.[2],[3]

"He notes that the percent of students who see regular marijuana use as carrying a great risk of harm has declined substantially since about 2005, and is still declining. Over the past 10 years, the percent seeing a great risk in regular marijuana use has fallen among 8th ­graders from 74 percent to 58 percent, among 10th ­graders from 66 percent to 43 percent and among 12th­graders from 58 percent to 32 percent."

"We found no evidence of intermediate-term effects of passage of state MMLs on the prevalence or frequency of adolescent nonmedical marijuana use in the states evaluated, with 2 minor exceptions. From 2003 through 2009, adolescent lifetime prevalence of marijuana use and frequency of daily marijuana use decreased significantly in Montana, as compared with a more modest decrease in lifetime prevalence and an increase in daily frequency observed in Delaware (Ps = .03). These 2 statistically significant findings do not appear to represent real effects. Our difference-in-differences study design involved 40 planned comparisons (before---after differences in treatment vs comparison states), and naturally 2 significant results (at the P < .05 level) of a possible 40 can be expected according to chance alone.
"Moreover, the pattern is not consistent with an effect of MMLs. A significant effect was found for lifetime marijuana use but not past-month marijuana use. Self-reported lifetime use requires a much longer recall period than past-month use and is characterized by higher measurement error.13 Also, one would expect the 30-day use measure to be more sensitive than lifetime use to the effects of a change in MMLs, because most of the period covered by respondents’ lifetime reports occurred before passage of an MML.
"Finally, the significant increase in daily marijuana use was observed for the comparison state of Delaware, which had not enacted an MML during the years under evaluation, whereas the frequency of daily marijuana use in Montana decreased. This is the opposite of
what would be expected if MMLs had the deleterious effect of increasing the frequency of nonmedical marijuana use.
"Conversely, the significant effects observed were found between the 2 states that differed the most on the timing of MML enactment, maximizing the length of the follow-up period. Hence, it is reasonable to suspect that enacting an MML may influence the prevalence and frequency of adolescent nonmedical marijuana use half a decade later, despite no evidence of more proximal effects."

"• Support for laws prohibiting consumption of marijuana in private has been in substantial decline since 1990 and has fallen by more than half from a high of 56% (in 1990) to 21% in 2019, the lowest level recorded by the survey. This trend is almost a mirror image of the pattern before 1990, when the proportion who believed private marijuana use should be prohibited more than doubled, from 25% in 1978 to its level of 56% in 1990 – also a dramatic shift. The trend for prohibition of marijuana use in public follows very closely the same overall pattern seen for private use, with support for prohibition of public use running about 30 percentage points higher in every year. In 2019 it was 49%, the second lowest level ever recorded by the survey (the lowest was in 2018 at 48%).

"• In 2019 the proportions of 12th grade students agreeing that use of LSD, heroin, and amphetamines in private should be prohibited by law continued their long declines and were near historic lows (Table 8-7). The decline has been weakest for heroin, which seems to have maintained its reputation as a very dangerous drug, and support for legal prohibitions against its use in private stood at 68% in 2019. Steeper declines have been apparent for LSD and amphetamines. For all three drugs, the trends for support of legal prohibitions against public use are similar to their trends for private use, although levels of support of legal prohibitions against public use are higher and are 60% or above in all years. Specifically, in 2019 all three drugs – LSD, heroin, and amphetamines – were at or near the lowest levels recorded by the survey.

"• The proportion of 12th graders who said smoking cigarettes “in certain specified public places” should be prohibited by law was 36% in 2019, a historic low. The proportion has dipped below the 40% level where it had hovered since 2013. In earlier years level of support hovered at around 45% since the 1980s and showed surprisingly little change given the steady decline in smoking prevalence over the course of the survey. Given recent widespread prohibitions of smoking in many public and private places, it is possible that the assumed definition of “certain specified public places” has expanded in the minds of many 12th graders.

"• Attitudes about the legality of drunkenness in public significantly declined in 2019 to 41%, a historic low. In the past decade the percentage of 12th grade students favoring prohibition of public drunkenness had varied within the narrow range of 46% to 50%. This historic low in 2019 joins historic lows in attitudes toward both smoking cigarettes and marijuana use in public, suggesting a growing, general opposition to legal prohibition of public drug use, at least for the most commonly used substances. For private drunkenness, support for a prohibition ranged from 19% to 23% over the past decade, and in 2019 registered at 21%."

"Underlying problems related to youth health concerns also need to be addressed. In many situations, the participants' symptoms appeared to be directly related to their life circumstances. Along with the challenges inherent in being an adolescent in today's complex world, some teens were also trying to deal with significant losses (death of a close friend or family member), extremely difficult family relationships, disappointments with friends, school and sports, and a fragile family and peer support network. The risk of substance use increases substantially when youth are attempting to deal with these kinds of situations in isolation. Although marijuana provided the youth with temporary relief, the underlying situation often went unattended – leading the teens into a regular pattern of use. Appropriate guidance and targeted support from counselors and health care providers must be sensitive to meeting the needs of youth as they work through such situations and life altering events. In addition, adults working with youth must find better ways to talk with young people about how they are coping with their health issues, including their marijuana use. Based on the experiences of youth in this study, there is a wide range of support that may benefit youth including counseling, stress management, social skills training, anger management, study skills, pain management, and sleep hygiene. The youth in this study had minimal access to these types of resources."

"Exposure to early life stress, even to more severe forms such as physical and sexual abuse and emotional neglect, is common in the general population. The degree of risk for adult psychopathology tends to be correlated with the severity of childhood maltreatment and the number of childhood SLE [stressful life events]. An important causal pathway that links early life stress to the onset of psychiatric disorders is the altered homeostasis in the HPA [hypothalamicpituitary-adrenal] axis and the altered stress response circuitry that underlies many disorders including anxiety, depression, PTSD, and addiction. There appears to be a direct pathway from chronic stress exposure in prepubertal children via adolescent problem drinking to alcohol and drug dependence in early adulthood that is independent of family history. Of course, this can only occur in individuals exposed to the availability of alcohol or drugs. Early life stress may increase vulnerability to addiction through permanent effects on the expression of genes within the mesolimbic dopamine reward pathway. Early onset of problem drinking in stress-exposed children may exacerbate the deleterious effects on the developing brain. Since a large proportion of stress-exposed children do not go on to develop addiction, clearly resilience factors, including gene–environment interactions, are important. This review of the literature indicates that prevention should focus on early intervention in problem families to forestall maltreatment. Adolescence is a critically vulnerable time for the development of risky drinking habits, and this is an area where prevention, through the development of positive family, peer, and neighborhood-mediating factors, is vital. A holistic approach to the treatment of alcohol and drug dependence is essential since treatment is unlikely to be effective unless underlying impediments such as early life stress are recognized and addressed."

"Youths who used illicit drugs in the past year were significantly less likely than youths who had not used drugs to report that they received prevention messages in a special class about alcohol or other drugs at school or as part of another regular class, such as a health class, although these differences were not large. Nearly half of youths who used illicit drugs in the past year reported that they received education or information about alcohol or other drugs as part of a regular class at school, and nearly 30% of youths who used illicit drugs reported being in a special class about alcohol or other drugs at their schools. Youths who were drunk on 51 or more days in the past year did not differ significantly from their counterparts with regard to receipt of alcohol or other drug education as part of a special class.

"In addition, findings from Table 13.8 suggest that youths’ exposure to prevention messages outside school, such as through the media, was fairly widespread but appeared to be unrelated to illicit drug use or being drunk on 51 or more days in the past year. Nearly 80% of youths who used illicit drugs and more than three-fourths of youths who were drunk on 51 or more days in the past year reported being exposed to prevention messages outside school."

"Juveniles using drugs or alcohol committed 1 in 10 of the nonfatal violent victimizations against older teens. This was 2-1/2 times higher than the percentage of victimizations against younger teens perceived to be committed by a juvenile who was using drugs or alcohol.

"Younger teens were more likely than older teens to report that their juvenile offender was not using drugs or alcohol. In about 4 in 10 victimizations against younger and older teens committed by juveniles, the victim could not ascertain whether or not the offender was using drugs or alcohol."

"Cannabis is perceived to be the easiest illicit substance to get hold of, with around one third of ESPAD students (32 %) rating cannabis as easily obtainable. More students in the Netherlands, Denmark, Czechia, Slovenia and Slovakia than in the other ESPAD countries perceived cannabis to be easily available (rates from 45 % to 51 %). The countries with the lowest perceived availability of cannabis were Kosovo (11 %), Ukraine (13 %), Romania (16 %) and North Macedonia (19 %). Boys were more likely than girls to consider cannabis to be easily available (ESPAD average: 34 % for boys versus 30 % for girls).

"Compared with cannabis, perceived availability was low for ecstasy (MDMA) (14 %), cocaine (13 %), amphetamine (10 %) and methamphetamine (8.5 %). These drugs were perceived to be more easily available in Bulgaria, Sweden and Denmark than elsewhere in Europe.

"The perceived availability of ecstasy was highest (over 20 %) in Slovakia, Czechia, Slovenia and the Netherlands, whereas for cocaine it was highest in Denmark and Ireland (22 % each). The countries with the lowest perceived availability of nearly all illicit drugs were Kosovo, Georgia and Romania.

"On average, 2.4 % of the ESPAD students reported having used cannabis for the first time at age 13 or younger. The highest proportions were found in France (4.5 %), Italy (4.4 %), Latvia (3.8 %), Cyprus (3.6 %) and Estonia (3.5 %). Rates of early onset of amphetamine/methamphetamine use were lower (ESPAD average: 0.5 %), with the highest proportion in Bulgaria (1.8 %). Boys were more likely than girls to have used cannabis or amphetamine/ methamphetamine at age 13 or younger. Similar results were found for early onset of ecstasy and cocaine use.

"The average prevalence of lifetime use of illicit drugs was 17 %, with considerable variation across ESPAD countries. It should be noted that this mainly relates to cannabis use (average lifetime prevalence of 16 %). The highest proportions of students reporting lifetime use of any illicit drug were found in Czechia (29 %), Italy (28 %), Latvia (27 %) and Slovakia (25 %). Particularly low levels (10 % or less) of lifetime illicit drug use were noted in Kosovo, Iceland, North Macedonia, Ukraine, Serbia, Sweden, Norway, Greece and Romania."

"Considering the ESPAD average, the lifetime prevalence of illicit drug use increased from 1995 to 2011 and has declined since then.

"Cannabis was the most widely used illicit drug in all ESPAD countries. On average, 16 % of students had used cannabis at least once in their lifetime. The countries with the highest prevalence of cannabis use were Czechia (28 %), Italy (27 %) and Latvia (26 %). The lowest levels of cannabis use (2.9-7.3 %) were reported in Kosovo, North Macedonia, Iceland and Serbia. On average, boys reported cannabis use to a larger extent than girls (18 % versus 13 %). This was the case in all countries except Bulgaria, Slovakia, Malta, the Netherlands and Czechia.

"Among all students who had used cannabis in the last 12 months (13 % of the total), the drug was used on average on about 10 occasions (9.9). In France, Italy, Serbia, Austria and Cyprus, cannabis was used once a month on average (12 or more occasions). The lowest average frequency of cannabis use was found in the Faroes (4.4 occasions). Overall, boys reported a higher frequency of cannabis use than girls.

"Overall, 7.1 % of the students had used cannabis in the last 30 days. A high variability was found among ESPAD countries, with the maximum rate observed in Italy (15 %) and the minimum in Kosovo (1.4 %). More boys than girls reported cannabis use in the last 30 days (boys 8.5 % versus girls 5.8 % on average), with statistically significant gender differences found in more than two thirds of ESPAD countries.

"To estimate the risk of cannabis-related problems, a core module, the CAST (Cannabis Abuse Screening Test) scale, was included in the ESPAD questionnaire. The prevalence of high-risk cannabis users (see the methodology section for a definition) ranged from 1.4 % to 7.3 % across countries, with an average of 4.0 %. Overall, the prevalence of high-risk cannabis users was higher among boys than girls (4.7 % versus 3.3 %). At the country level, statistically significant gender differences with higher rates among boys were found in 16 ESPAD countries.

"Trends in cannabis use indicate a general increase in both lifetime and last-30-day use between 1995 and 2019, from 11 % to 16 % and from 4.1 % to 7.4 %, respectively. Both prevalence rates reached their highest levels in 2011, with lifetime use slightly decreasing thereafter and current use levelling off.

"On average, 1-2 % of the ESPAD students had ever used an illicit drug other than cannabis at least once. After cannabis, the most widely used illicit drugs were ecstasy (MDMA), LSD (lysergic acid diethylamide) or other hallucinogens, cocaine and amphetamine. Lifetime prevalence rates for methamphetamine, crack, heroin and GHB (gammahydroxybutyrate) were lower than those for the other illicit drugs (about 1.0 % on average). At the country level, higher rates of lifetime use were found in Estonia and Latvia (lifetime use of ecstasy, LSD or other hallucinogens of about 5.0 %)."

"Zambon et al also found that having a good relationship with a best friend was related to increased use of cannabis, alcohol, and tobacco. Similarly, Hoel et al³⁹ reported that although abstainers are successful in many social arenas, they socialize less frequently with friends than youth who drink, while a Finnish study⁴⁰ indicated that moderate use of alcohol among adolescents was associated with a positive self-image in social relationships. Another
study,⁴¹ performed in New Zealand, also indicated an association between a high level of connectedness to friends and an increased level of smoking and use of cannabis in the previous month.
"In addition, and contrary to previous research,²³ our study does not confirm the negative effect of cannabis on academic performance among COG youth. In our case, they are more likely to be high school students and they report similar grades as abstainers, even though they skip class more often."

"Interestingly, our results do not confirm our hypothesis of better overall functioning among abstainers. In fact, what our research indicates is that the main difference between COG [cannabis use only group] youth and abstainers [those abstaining from all drugs] is that the former are more socially driven: they are significantly more likely to practice sports, and they have a better relationship with their peers. Moreover, even though they are more likely to skip class, they have the same level of good grades; and although they have a worse relationship with their parents, they are not more likely to be depressed. Nevertheless, our results seem to indicate that, although typical of the adolescence process, having good support from friends together with a less solid relationship with parents is a risk factor for occasional cannabis use."

"In the United States in the 1970s and 1980s, cannabis use appears to have increased the risk of discontinuing a high school education, and of experiencing job instability in young adulthood (Newcombe and Bentler, 1988). The apparent strength of these relationships in cross-sectional studies (e.g. Kandel, 1984) has been exaggerated because those adolescents who are most likely to use cannabis have lower academic aspirations and poorer high school performance prior to using cannabis than their peers who do not (Newcombe and Bentler, 1988). It remains possible that factors other than the marijuana use account for apparent causal relations. To the extent they may exist, these adverse effects of cannabis and other drug use upon development over and above the effect of pre-existing nonconformity may cascade throughout young adult life, affecting choice of occupation, level of income, choice of mate, and the quality of life of the user and his or her children."

"Our results are not consistent with the hypothesis that the legalization of medical marijuana caused an increase in the use of marijuana and other substances among high school students. In fact, estimates from our preferred specifications are consistently negative and are never statistically distinguishable from zero."
"There is little evidence that marijuana use is related to the legalization of medical marijuana in either of these data sources [*], a result that is consistent with research showing that marijuana use among adults is more sensitive to changes in policy than marijuana use among youths (Farrelly et al. 1999; Williams 2004)."
[*] data sources are the National Longitudinal Survey of Youth 1997 (NLSY97) and the Treatment Episode Data Set (TEDS)

"In line with previous work, we found that cannabis users had lower teenage IQ scores and poorer educational performance than teenagers who had never used cannabis. At the same time, cannabis users also had higher rates of childhood behavioural problems, childhood depressive symptoms, other substance use (including use of cigarettes and alcohol) and maternal use of cannabis during pregnancy. After adjustment to account for these group differences, cannabis use by the age of 15 did not predict either lower teenage IQ scores or poorer educational performance. These findings therefore suggest that cannabis use at the modest levels used by this sample of teenagers is not by itself causally related to cognitive impairment. Instead, our findings imply that previously reported associations between adolescent cannabis use and poorer intellectual and educational outcomes may be confounded to a significant degree by related factors."

"In summary, the notion that cannabis use itself is causally related to lower IQ and poorer educational performance was not supported in this large teenage sample. However, this study indeed has limitations, in particular the young age of outcome assessment. While we have demonstrated that confounding may be an explanation for links between cannabis use and poorer outcomes, large prospective cohorts tracking young people prior to, during and after stopping cannabis use, using more objective measures of drug use (e.g. the new NIH-funded ‘ABCD study’ in the United States; National Institute on Drug Abuse, 2015) are required before we can make strong conclusions. Cigarette smoking in particular has once again (Hooper et al., 2014; McCaffrey et al., 2010; Silins et al., 2014; Stiby et al., 2014) been highlighted as an important factor in adolescent outcomes, as well as a robust independent predictor of educational performance, and the reasons for this need to be elucidated."

"Compared with those in our sample who had never tried cannabis, teenagers who had used cannabis at least 50 times were 17 times more likely (84% vs. 5%) to have smoked cigarettes more than 20 times in their lifetime. Accounting for group differences in cigarette smoking dramatically attenuated the associations between cannabis use and both IQ and educational performance. Further, even after excluding those who had never tried cannabis, cigarette users were found to have lower educational performance (adjusted performance 2.9 percentage points lower, approximately equivalent to dropping two grades on one subject taken at GCSE) relative to those who had never tried cigarettes. A relationship between cigarette use and poorer cognitive (Chamberlain et al., 2012; Hooper et al., 2014; Weiser et al., 2010; Whalley et al., 2005) and educational (McCaffrey et al., 2010; Silins et al., 2014; Stiby et al., 2014) outcomes has been noted previously, and may have a number of explanations. Cigarette use may have a negative impact on cognitive ability. However, this is not supported by the experimental psychopharmacology literature, which robustly shows that acute nicotine administration results in transient cognitive enhancement (Heishman et al., 2010). Alternatively, reverse causality may contribute to this relationship, for example performing poorly at school may lead to increased engagement in risky behaviours such as cigarette smoking. Further, residual confounding may contribute to this link: cigarette smoking may be a marker of unmeasured factors, for example social adversity during adolescence, that influence both IQ and educational attainment."

"In the present study, the most persistent adolescent-onset cannabis users evidenced an average 8-point IQ decline from childhood to adulthood. Quitting, however, may have beneficial effects, preventing additional impairment for adolescent-onset users. Prevention and policy efforts should focus on delivering to the public the message that cannabis use during adolescence can have harmful effects on neuropsychological functioning, delaying the onset of cannabis use at least until adulthood, and encouraging cessation of cannabis use particularly for those who began using cannabis in adolescence."

"Our findings suggest that regular cannabis use before age 18 y predicts impairment, but others have found effects only for younger ages ^{(10, 15)}. Given that the brain undergoes dynamic changes from the onset of puberty through early adulthood ^{(37, 38)}, this developmental period should be the focus of future research on the age(s) at which harm occurs."

"The younger and more often teens use marijuana, the more likely they are to engage in other substance use and the higher their risk of developing a substance use disorder. Among high school students, 7.5 percent used marijuana for the first time before the age of 13. CASA’s analysis of national data finds that the average age of initiation of marijuana use among high school students is 14.3 years old. Compared to those who began using marijuana after age 21, those who first used it before age 15 are:
• More likely to have ever smoked a cigarette (93.3 percent vs. 86.4 percent);
• More than twice as likely to have ever misused controlled prescription drugs (56.5 percent vs. 22.9 percent); and
• Two and a half times as likely to have ever used other illicit drugs (70.2 percent vs. 27.8 percent)."

"Annual marijuana prevalence peaked among 12th graders in 1979 at 51%, following a rise that began during the 1960s. Then use declined fairly steadily for 13 years, bottoming at 22% in 1992—a decline of more than half. The 1990s, however, saw a resurgence of use. After a considerable increase (one that actually began among 8th graders a year earlier than among 10th and 12th graders), annual prevalence rates peaked in 1996 at 8th grade and in 1997 at 10th and 12th grades. After these peak years, use declined among all three grades through 2007 or 2008. After these declines, an upturn occurred in use in all three grades, lasting for three years in the lower grades and longer in grade 12. Annual marijuana prevalence among 8th graders increased in use from 2007 to 2010, decreased slightly from 2010 to 2012, and then declined significantly in 2016. Among 10th graders, use increased somewhat from 2008 to 2013 and then declined after that. Among 12th graders, use increased from 2006 to 2011 and then held level through 2016. As shown in Table 8, daily use increased in all three grades after 2007, reaching peaks in 2011 (at 1.3% in 8th), 2013 (at 4.0% in 10th), and 2011 (at 6.6% in 12th), before declining slightly since. Daily prevalence rates in 2016 were 0.7%, 2.5%, and 6.0%, respectively, with one in seventeen 12th graders smoking daily."

"High school students are more likely to use marijuana than to smoke cigarettes. High school students are:
"• More likely to have tried marijuana than tobacco (24 percent vs. 15 percent); and
"• More likely to say their close friends use marijuana than smoke cigarettes (51 percent vs. 39 percent)."

"Teens also say they are seeing more peers in school smoking marijuana and more teens (73 percent) report having friends who smoke marijuana regularly (71 percent) – significantly higher than four years ago. Since 2008, there have also been significant declines in teen perceptions that they will lose respect, harm themselves, or mess up their lives if they use marijuana."

"The apparent strength of these relationships in cross-sectional studies (e.g. Kandel, 1984) has been exaggerated because those adolescents who are most likely to use cannabis have lower academic aspirations and poorer high school performance prior to using cannabis than their peers who do not (Newcombe and Bentler, 1988). It remains possible that factors other than the marijuana use account for apparent causal relations. To the extent they may exist, these adverse effects of cannabis and other drug use upon development over and above the effect of pre-existing nonconformity may cascade throughout young adult life, affecting choice of occupation, level of income, choice of mate, and the quality of life of the user and his or her children."

"The 'School to Prison Pipeline' and similar concepts are used to describe how some youth are seemingly on a one-way path that begins with becoming disconnected with school, then continues to dropping out, and later entering the justice system. School policies that rely on overly punitive responses to student behavior and a reliance on law enforcement to address school discipline have led to increases in suspensions, expulsions, and referrals to the juvenile justice system for even minor infractions. As a result, students are taken out of school, missing important educational opportunities and, in some cases, made unable to return to school. The School to Prison Pipeline not only sends students directly into the justice system, but missed educational opportunities are linked to increased risk that a student will one day be involved in the justice system."

"The risk factors were stronger predictors of substance use outcomes compared to the protective factors, regardless of grade level or substance use type. In particular, the individual and peer risk factors were strongly related to lifetime and recent use of cigarettes, alcohol, and marijuana. Among the protective factors, the strongest associations with substance use were found in the community domain. Several age-related differences in the associations were also found, suggesting that family and community factors were more salient among younger grades whereas peer and school factors were stronger among older adolescents."

"Addictive substances also adversely affect brain development and maturation in the areas related to motivation, judgment, inhibition and selfcontrol.²⁶ As a result, addictive substances impair the judgment of teens in the face of potential rewards, leading not only to their engagement in risky behaviors--such as driving while under the influence of alcohol or other drugs or participating in unsafe sexual practices--but also to continued use of addictive substances despite negative consequences.²⁷”

"Social learning variables, peer attitudes (prevalence of norms favourable to deviant behaviour), personal approval (adoption of deviant norms), and peer behaviour have an effect on frequency of alcohol use and alcohol abuse. Alcohol expectancies and peer delinquency predict alcohol consumption of adolescents.

"Going out most evenings and the use of cannabis by peers and older siblings is associated with adolescents’ use of cannabis.

"Having school-related problems is a strong predictor in all stages of cannabis involvement (initiation of experimental use, initiation of regular use, progression to regular use, failure to discontinue, experimental use, failure to discontinue, regular use)."

"In sum, risk taking declines between adolescence and adulthood for two, and perhaps, three reasons. First, the maturation of the cognitive control system, as evidenced by structural and functional changes in the prefrontal cortex, strengthens individuals’ abilities to engage in longer-term planning and inhibit impulsive behavior. Second, the maturation of connections across cortical areas and between cortical and subcortical regions facilitates the coordination of cognition and affect, which permits individuals to better modulate socially and emotionally aroused inclinations with deliberative reasoning and, conversely, to modulate excessively deliberative decision-making with social and emotional information. Finally, there may be developmental changes in patterns of neurotransmission after adolescence that change reward salience and reward-seeking, but this is a topic that requires further behavioral and neurobiological research before saying anything definitive."

"In commenting on problem behaviors among youth, Jessor and Jessor (1975) and later Jessor (1984) argued that adolescence is a period in which youth reject conventionality and traditional authority figures in an effort to establish their own independence. For a significant number of adolescents, this rejection consists of engaging in a number of 'risky' behaviors, including drug and alcohol use. Within the past few years, researchers and practitioners have begun to focus on this tendency, suggesting that drug use may be a 'default' activity engaged in when youth have few or no opportunities to assert their independence in a constructive manner (Benard 1994; gentler 1992; Carnegie Council on Adolescent Development 1992; Cato 1992; Maddahian et al. 1988; Pransky 1991). They note that in contemporary American society, youth have very few opportunities to participate in activities that allow them to develop a sense of independence and assume significant responsibilities. Such efforts must allow youth to exercise considerable control over activity development and implementation."

"Marijuana is one drug that is affected by some very specific policies, including medicalization and legalization of recreational use by adults. The effects on youth behaviors and attitudes of recent changes in a number of states will need to be carefully monitored in future years. Currently, marijuana does not hold the same appeal for youth as it did in the past, and today’s annual prevalance among 12th graders of 36% is considerably lower than rates exceeding 50% in the 1970s (documented by this project). However, if states that legalize recreational marijuana allow marijuana advertising and marketing, then prevalence could rebound and approach or even surpass past levels."

"Family risk factors in the development of adolescent substance use are: known familial substance use or abuse, and a lack of parental supervision. Protective factors are: warm and supportive family environment, prosocial family processes (rules, monitoring) and attachment."

"The disciplinary policies in effect in many schools today apply zero tolerance to public school students in three draconian ways. First, they are blind to the most basic distinctions between types of offenses. In many schools, dangerousness is irrelevant; the penalties are the same for weapons and alcohol, sale and possession, robbery, and disorderly offenses. Offenses that used to be resolved informally with an apology or an after-school detention now lead to formal disciplinary hearings. Second, they require a severe sanction, typically suspension or expulsion, for all of these offenses, regardless of the circumstances of the offense or the intent, history and prospects of the offender. Third, these policies generally mandate some degree of information-sharing with law enforcement. This multiplies the consequences of student misconduct in two directions: out-of-school offenses referred to the child’s school may result in suspension or other sanctions,¹⁸ and in-school infractions referred to law enforcement agencies may result in juvenile or criminal prosecution."

"Another point worth keeping in mind is that there tends to be a continuous flow of new drugs onto the scene and of older ones being rediscovered by young people. Many drugs have made a comeback years after they first fell from popularity, often because knowledge among youth of their adverse consequences faded as generational replacement took place. We call this process 'generational forgetting.' Examples include LSD and methamphetamine, two drugs used widely in the 1960s that made a comeback in the 1990s after their initial popularity faded as a result of their adverse consequences becoming widely recognized during periods of high use. Heroin, cocaine, PCP, and crack are some others that have followed a similar pattern. LSD, inhalants, and ecstasy have all shown some effects of generational forgetting in recent years — that is, perceived risk has declined appreciably for those drugs — which puts future cohorts at greater risk of having a resurgence in use. In the case of LSD, perceived risk among 8th graders has declined noticeably, and more students are saying that they are not familiar with the drug. It would appear that a resurgence in availability (which declined very sharply after about 2001, most likely due to the FDA closing a major lab in 2000) could generate another increase in use."

"• Alcohol and nicotine in all of its forms (including smoking cigarettes, using smokeless tobacco, and vaping nicotine) are the two major licit drugs that are included in the MTF surveys, though even these are now legally prohibited for purchase by those under the age of 21, which is virtually all of our respondents. Alcohol use is more widespread than use of illicit drugs. Nearly three fifths of 12th grade students (59%) have at least tried alcohol, and about three out of ten (29%) are current drinkers – that is, they reported consuming some alcohol in the 30 days prior to the survey (Table 4-2). Even among 8th graders, a quarter (25%) reported any alcohol use in their lifetime, and one in 13 (7.9%) is a current (past 30-day) drinker.⁵

"• Of greater concern than just any use of alcohol is its use to the point of intoxication: In 2019 more than two out of five 12th graders (41%), one quarter of 10th graders (26%), and about one tenth of all 8th graders (10.1%) said they had been drunk at least once in their lifetime. The levels of self-reported drunkenness during the 30 days immediately preceding the survey are high: 17.5%, 8.8%, and 2.6%, respectively, for grades 12, 10, and 8.

"• Another measure of heavy drinking asks respondents to report on how many occasions during the last two weeks they had consumed five or more drinks in a row. In 2019 prevalence levels for this behavior, which we refer to as binge drinking, were 14.4%, 8.5%, and 3.8% in the 12th, 10th, and 8th grade, respectively.⁶

"• Extreme binge drinking, also known as high intensity drinking,7 refers to the consumption of 10 or more drinks in a row or 15 or more drinks in a row on a single occasion. One of the most concerning findings from the alcohol frequency results relate to this outcome. Table 4-4b shows that prevalence of having 5 or more drinks in a row in the prior two weeks – our standard measure of “binge drinking” – was 14.4% for 12th graders in 2019, but more than one third of them (5.3% of the total) said that they had 10 or more drinks in a row, and more than one fifth of them (3.2% of the total) reported 15 or more drinks in a row. Similarly, in 10th and 8th grades between 39% to 46% of youth who reported 5 or more drinks in a row in the prior two weeks reported 10 or more drinks in a row during the same period. (Questions about 15 or more drinks in a row were not asked of 8th and 10th graders.)"

"• In 2012, 75.9 percent of youths aged 12 to 17 reported having seen or heard drug or alcohol prevention messages in the past year from sources outside of school, such as from posters or pamphlets, on the radio, or on television. This rate in 2012 was similar to the 75.1 percent reported in 2011, but was lower than the 83.2 percent reported in 2002 (Figure 6.6). In 2012, the prevalence of past month use of illicit drugs among those who reported having such exposure (9.4 percent) was not significantly different from the prevalence among those who reported having no such exposure (10.0 percent).

"• In 2012, 75.0 percent of youths aged 12 to 17 enrolled in school in the past year reported having seen or heard drug or alcohol prevention messages at school, which was similar to the 74.6 percent reported in 2011, but was lower than the 78.8 percent reported in 2002 (Figure 6.6). In 2012, the prevalence of past month use of illicit drugs or marijuana was lower among those who reported having such exposure in school (8.9 and 6.7 percent for illicit drugs and marijuana, respectively) than among youths who were enrolled in school but reported having no such exposure (12.3 and 9.7 percent)."

"We replicated the findings of Wall et al. (2) that marijuana use was higher in states that have passed MMLs, and our analysis suggests this is unlikely to be a causal association. Our difference-in-differences estimates suggest little detectable effects of passing MMLs on marijuana use or perceived riskiness of use among adolescents or adults, which is consistent with some limited prior evidence on arrestees and emergency department patients (17). Future analyses that take advantage of additional policy changes may provide further evidence on this question, but our results suggest that such analyses should adequately control for potential confounding by unmeasured state characteristics."

"The findings of this study provide one of the first in-depth descriptions of youths' use of marijuana for non-recreational purposes, adding to the growing body of research on the use of drugs to self-medicate among young people. Teens involved in regular and long-term use of marijuana for relief constructed their use of marijuana as essential to feeling better or 'normal' in situations where they perceived there were few other options available to them. Unlike the spontaneity typically involved in recreational use, these youth were thoughtful and prescriptive with their marijuana use – carefully monitoring and titrating their use to optimize its therapeutic effect. The findings also point to important contextual factors that further support youth's use of marijuana for relief that extend beyond the availability of marijuana and dominant discourses that construct marijuana as a natural product with medicinal properties."

"Of key importance in the findings are the unmet health needs of these youth. Health issues such as depression, insomnia, and anxiety were significant problems that interfered with these youths' ability to function at school, maintain relationships with family and friends, and feel that they could live a normal life. The level of distress associated with these health concerns, along with the lack of effective interventions by heath care providers and family members appeared to leave them with few alternatives. Researchers have reported that when adolescents in rural communities experience barriers to seeking health care, they think they can take care of the problems themselves [30]. Similarly, our study participants believed that their best option was to assume responsibility for treating their problems by using marijuana. Unpleasant side effects with prescribed medications and long, ineffective therapies resulted in little hope that the medical system could be counted on as beneficial. In contrast, marijuana provided these youth with immediate relief for a variety of health concerns. Nevertheless, the regular use of marijuana put youth at risk. Cannabis use has been identified as a risk factor for mental illness such as psychosis, schizophrenia [21,31,32] and psychiatric symptoms such as panic attacks [33]. Teens who smoked marijuana at least once per month in the past year were found to be three times more likely to have suicidal thoughts than non-users [34], and there is evidence that exposure to cannabis may worsen depression in youth [35]. Marijuana use among youth has also been associated with other substance use and school failure [36]. What is interesting is that the findings of this study suggest that youth have little awareness of some of these risks; rather, some are using marijuana to counteract these very problems (e.g., depression, school failure). Teens' perceptions that their health concerns were not addressed suggest that more attention is needed to assess these issues and ensure that other options are available to them. Parents and health care providers need to make a concerted effort to not only understand the pressures and influences on youth [37], but also gain a better understanding of the effect of youths' health problems on their ability to engage in healthy lifestyle choices."

"Prevalence of cigarettes is generally higher than for any of the illicit drugs, except for marijuana. More than one fifth (22.3%) of 12th graders reported having tried cigarettes at some time, and one in seventeen (5.7%) smoked in the prior 30 days. Even among 8th graders, one tenth (10%) reported having tried cigarettes and 2.3% reported smoking in the prior 30 days. Among 10th graders, 14.2% reported having tried cigarettes, and 3.4% reported smoking in the prior 30 days. The percentages reporting smoking cigarettes in the prior 30 days are actually far lower in all three grades in 2019 than the percentages reporting using marijuana in the prior 30 days: 2.3% for cigarettes versus 6.6% for marijuana in 8th grade; 3.4% versus 18.4% in 10th grade; and 5.7% versus 22.3% in 12th grade. These numbers reflect mostly the considerable, steady decline in cigarette use that has occurred over the past two decades. Among 8th, 10th and 12th graders, lifetime prevalence of marijuana use in 2019 was also higher than lifetime prevalence of cigarette use. (Annual prevalence of cigarette use is not assessed.)"

"Overall, these data reveal that, while use of individual drugs (other than marijuana) may fluctuate widely, the proportion using any of them is much more stable. In other words, the proportion of students prone to using such drugs and willing to cross the normative barriers to such use changes more gradually. The usage rate for each individual drug, on the other hand, reflects many more rapidly changing determinants specific to that drug: how widely its psychoactive potential is recognized, how favorable the reports of its supposed benefits are, how risky its use is seen to be, how acceptable it is in the peer group, how accessible it is, and so on."