Substance Use. Tobacco. Alcohol

Experimentation with substances such as alcohol, tobacco, and drugs is common during adolescence. Some teen­agers may try these substances infrequently or in small amounts, which may not significantly impact their lives.

Other more vulnerable adolescents become dependent or addicted, which can have devastating effects on their health and how they function in society. The younger a person uses drugs or alcohol, the more likely he or she is to abuse the substance as an adult. Substance use is asso­ciated with other risk behaviors, and contributes to sui­cides, motor vehicle crashes, pregnancy, STIs, violence, and homicides in young people. Having a supportive family and opportunities for economic development seems to protect against substance abuse in teenagers.

Tobacco. Tobacco is one of the most addictive drugs known to humans and is the second leading cause of death worldwide. Tobacco use is associated with lung, esophageal, and mul­tiple other cancers, cardiovascular disease, and pulmonary diseases such as pneumonia, chronic obstructive pulmo­nary disease, and bronchitis. Tobacco is available in many forms: cigarettes, hookahs, cigars, kreteks or ‘clove cigar­ettes,’ pipes, bidis, and smokeless varieties. WHO estimates that of the 300 million young people who currently smoke, half will die of smoking-related causes later in life, the vast majority of these deaths occurring in the developing world (WHO, 2005).

Women who smoke during pregnancy are more likely to have infants who are premature and small for their age. The hundreds of millions of children exposed to secondhand smoke are more likely to die from sudden infant death syndrome and suffer from ear infections, upper respiratory infections, asthma, pneumonia, and malignancies. Children are most likely to be exposed to secondhand smoke in areas in South and East Asia.

Although many of the adverse health effects do not become evident until adulthood, tobacco use is in many ways a disease of adolescence. The vast majority of adult smokers started their habit during adolescence. The Global Youth Tobacco Survey of young people at nearly 400 different sites found that 17.3% currently use tobacco, with the highest use among males in the Americas and Europe (Figure 6). Young people who desire peer accep­tance or to appear mature or rebellious may try smoking. Harmful health effects may be unknown to a young per­son, or may seem a lifetime away.

Figure 6. Prevalence of current tobacco use in youth aged 13-15 years, stratified by WHO region. Current tobacco use is defined as used tobacco products during the past 30 days. Reproduced from Warren CW, Jones NR, Eriksen MP, and Asma S, for the Global Tobacco Surveillance System (GTSS) Collaborative Group (2006) Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet 367: 749-753, with permission from Elsevier

In the United States, having a peer group that smokes is the most important predictor of smoking in adolescence. Teenagers whose parents smoke are also more likely to use tobacco. Teen­agers who smoke are more likely to become addicted than adults, often becoming addicted within the first few weeks after trying their first cigarette.

For these reasons, tobacco companies target young people, especially those living in developing countries using ‘teen-friendly’ campaigns such as ‘‘Joe Camel,’’ fla­vored tobacco, individually sold cheap tobacco ‘sticks,’ and promotions where teenagers can win tobacco- branded items. Media campaigns generally portray people who smoke as attractive, energetic, and healthy.

In developing regions, regulations against marketing and sales to minors are more relaxed, and tobacco is cheaper and readily available. Some economically disadvantaged adolescents may choose to purchase tobacco instead of food as it acts as an appetite suppressant; girls in indus­trialized countries may also smoke for this reason. Even in industrialized countries, cigarette use is associated with lower socioeconomic status.

Although most adolescent smokers want to quit, this act is very challenging for those who are not only addicted but also surrounded by peers, movie stars, and even their own physicians using tobacco. Pharmacotherapy and behavioral therapy have been shown to help adults stop smoking, but are not as well studied in teenagers. Young women are often worried about the potential for weight gain associated with smoking cessation. All youth are at risk to suffer nicotine withdrawal, which causes mood changes, insomnia, and restlessness.

Increasing the price of tobacco through taxation has been shown to prevent some young people from smoking, since they tend to be more sensitive to price than adults. Banning tobacco vending machines, enforcing a minimum age to purchase tobacco, and establishing smoke-free areas has also been effective in reducing smoking initia­tion in young people. Nearly 200 countries have signed the Framework Convention on Tobacco Control (FCTC), a treaty designed to control tobacco use.

The FCTC recommends that governments ban tobacco advertis­ing and marketing toward children under 18 years of age. Many mass public health campaigns designed to educate young people on the dangers of tobacco use have been launched across the globe, some of which have been demonstrated to be effective.

Alcohol. Alcohol is probably the most widely used drug in the world. It is cheap, readily available, and sold in many different formulations in industrialized regions. In devel­oping countries, alcohol use is associated with importa­tion of Western culture and improving economies.

Adolescents generally do not experience the long-term adverse health consequences that adults do, such as delir­ium tremens, stomach ulcers, pancreatitis, pancreatic and stomach cancer, cirrhosis, and liver failure. However, young people who drink are more likely to abuse alcohol and incur alcohol-related injuries as adults, especially those that initiate alcohol use at a younger age. Moreover, the psychosocial implications for adolescents who abuse alcohol cannot be underestimated.

Young people whose peer group or parents drink are more likely to use alcohol. Those with low self-esteem, depression, attention-deficit disorder, and antisocial dis­order are also more likely to abuse alcohol, often creating a maladaptive cycle. At first, an adolescent who imbibes in small quantities may feel elated, relaxed, and friendly, features that attract young people who are trying to assimilate with their peer group. Young people, espe­cially boys, are more likely than adults to ‘binge drink,’ (>5 consecutive drinks) in order to become intoxicated (Figure 7).

Figure 7. Percentage of 15-year-old children who have been drunk two or more times. Adapted from Currie C, et al. (eds.) (2004) Young People's Health in Context: Health Behavior in School-Aged Children (HBSC) International Report from the study 2001/2002 Survey. Copenhagen: WHO Regional Office for Europe, 2004: 80. (Health Policy for Children and Adolescents, No. 4), with permission from the WHO Regional Office for Europe

Teenagers who drink large amounts can become moody, angry, and have impaired judgment, and are more likely to take risks, such as drive quickly, physi­cally fight, use other substances, and engage in unpro­tected sexual activity, placing them at risk for STIs and HIV. Alcohol is involved in a large proportion of fatal motor vehicle crashes, drownings, and suicides involving adolescents in the industrialized world. Alcohol is now the leading cause of death in young men in Europe, largely due to alcohol-related injuries. Young alcohol users are also at higher risk for school absenteeism and tend to have trouble keeping a job because of missed hours.

Some companies market alcoholic products to young people, selling bottles that may be small enough to be concealed in a backpack, or in formulations that appeal to teenagers, such as wine coolers and alcoholic lemonades that are brightly colored and taste fruity. Adolescents who drink these products may underestimate the amount of alcohol they ingest.

Educational efforts have largely been ineffective in changing adolescent behavior regarding alcohol use. Estab­lishment of a minimum drinking age and taxation of alco­holic drinks have curtailed use in many countries. For those who abuse alcohol, counseling and treatment are necessary to improve health. Research on adolescent alcohol abuse in developing countries is limited; programs developed in industrialized countries may not necessarily be effective.

Other Drugs. Marijuana is probably the most commonly used illicit drug worldwide. Adolescents who use marijuana feel relaxed, euphoric, and have lowered inhibitions; some may feel anxious and have increased appetite. In most regions where marijuana is illegal and unregulated, the product may be mixed with other substances such as PCP and used unknowingly by a young person.

Marijuana can be smoked or eaten. When smoked, it theoretically can damage lung tissue like tobacco, although marijuana users tend to use less frequently than cigarette smokers. Adolescents who regularly use marijuana can become psychologically dependent, and are at risk for amotivational syndrome, in which they do not actively engage in society.

Marijuana does not contain nicotine, and physical addiction has never been demonstrated. How­ever, teenagers who smoke marijuana may be more likely to try other more dangerous substances, hence its controver­sial role as a ‘gateway drug,’ causing many law enforcement agencies to enforce regulations against its sale.

Adolescents who are addicted to other illicit drugs are at risk for overdose, dependency, suicide, and death. They may resort to selling their bodies or drugs, or committing crimes to finance their habit. They are more likely to be jailed, drop out of school, and live on the streets. Young people are the most likely age group to abuse intravenous drugs, which has contributed to the spread of HIV in many countries.

Intravenous drug abusers are also at risk for other infections including hepatitis C, which causes liver failure. In the industrialized world, there has been increasing attention surrounding the illicit use of pre­scription medications, including painkillers, sedatives, and stimulants. Teenagers may underestimate the danger in these drugs because they are otherwise legal, and may use a multitude of substances, placing them at risk for cardiac arrhythmias and sudden death.

Cocaine, including crack cocaine, has had a devastating effect on adolescents in every socioeconomic class. Methamfetamine (‘crystal meth’) has reached near-epidemic proportions in parts of the United States because it is highly addictive and easy to make from cheap household products.

Adolescents, especially younger teenagers, may experiment with inhalants that are cheap and readily available, yet dissolve brain cells and can cause sudden death. Phencyclidine (PCP) use causes young men to become a dangerous combination of physically violent, psychotic, and numb to pain. Numerous ‘club drugs’ in the industrialized world such as Ecstasy make adolescents euphoric and augments their sexual drive while lowering inhibitions, placing them at risk for pregnancy and STIs. Teenagers may combine these drugs with erection-aiding medications in order to combat impotence, which can be a side effect.