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https://doi.org/10.1037/0000298-033 APA Handbook of Adolescent and Young Adult Development, L. J. Crockett, G. Carlo, and J. E. Schulenberg (Editors) Copyright © 2023 by the American Psychological Association. All rights reserved.
Adolescence and early adulthood are high-risk developmental periods for tobacco, alcohol, and illicit drug use (Degenhardt et al., 2016). Across all age groups, past-year prevalence is highest among those aged 18 to 20 for marijuana and those aged 21 to 25 for alcohol and drugs other than marijuana. Similarly, past-year prevalence of substance use disorders is highest among those aged 18 to 25 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). The majority of substance use initiation occurs during adolescence and early adulthood. Peak incidence, that is, the highest rate of first-time use, occurs at ages 16 to 17 for alcohol and mar- ijuana and 18 to 20 for cigarettes. Later initiation is much less common: Among adults aged 26 and older, less than 1% initiate cigarette, alcohol, or marijuana use in any given year (SAMHSA, 2019). Unique features of these developmental periods make experimentation and escalating use more likely and exacerbate potential harms (Hall et al., 2016). The initiation and escalation of substance use during adolescence and early adulthood is of increasing concern due to the immediate effects of acute intoxication (e.g., injury, assault, death) and the strong contributions of lifetime substance use to the global burden of disease (Degenhardt et al., 2016).
SUBSTANCE USE PREVALENCE AND THEORY
Multiple theories provide explanations for substance use and misuse across the lifespan, highlighting bio- logical, psychological, and sociological mechanisms (Bahr & Hoffmann, 2016; Lettieri et al., 1980). We focus here on major theoretical themes that pro- vide a framework for understanding substance use among adolescents and young adults.
Theories and Conceptual Models of Adolescent and Young Adult Substance Use Petraitis et al. (1995) posited that young people’s substance use is complex and best explained by integrating cognitive, learning, attachment, and intrapersonal theories. As this review remains one of the most comprehensive overviews of substance use theory, we outline Petraitis and colleagues’ summary. Cognitive-affective theories (e.g., the- ory of planned behavior; Ajzen, 1985) focus on substance-specific expectations and perceptions, suggesting that the decision to use is driven by perceived costs and benefits (Petraitis et al., 1995). Compared with adults, young people perceive lower harm from cigarette, marijuana, and heavy alcohol use (SAMHSA, 2019). Youth also weigh costs and
Ch a P t e r 33
SUBSTANCE USE ACROSS ADOLESCENCE AND EARLY ADULTHOOD: PREVALENCE,
CAUSES, DEVELOPMENTAL ROOTS, AND CONSEQUENCES
Jennifer L. Maggs, Brian H. Calhoun, and Hannah K. Allen
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benefits of substance use differently (Steinberg, 2005). Social learning theories (e.g., social cogni- tive learning theory; Bandura, 1986) expand on cognitive-affective theories by highlighting interper- sonal factors as the root of substance use attitudes (Petraitis et al., 1995). These theories identify a sequence of substance use involvement: observa- tion and imitation of substance use among peers and role models, social reinforcement and encour- agement, and development and reinforcement of positive expectancies for future substance use.
Commitment and social attachment theories (e.g., social development model; Catalano & Haw- kins, 1996; Hawkins & Weis, 1985) also emphasize peer influence but focus on a lack of conventional bonds. Weak attachments to institutions and individuals that discourage deviant behavior (e.g., school, religion, family) may lead to affiliation with substance-using peers and use itself (Petraitis et al., 1995). Lastly, Petraitis et al. (1995) highlighted theories focused on intrapersonal risk factors (e.g., self-derogation theory; Kaplan, 1975), which posit that individual characteristics such as personality and affect underlie motivation and use regardless of social situation. Given that substance use is influenced by many factors, theories that integrate cognitive, learning, attachment, and interpersonal constructs (e.g., problem-behavior theory; Jessor et al., 1991) provide the most comprehensive under- standing (Petraitis et al., 1995).
Current and Historical Substance Use Prevalence Among Adolescents and Young Adults Multiple population-based epidemiologic surveys assess adolescent and young adult substance use in the United States, including the National Survey on Drug Use and Health (NSDUH), Monitoring the Future (MTF), and the Youth Risk Behavior Surveil- lance System (YRBSS). Main prevalence estimates in this chapter are from NSDUH (Substance Abuse and Mental Health Services Administration [SAM- HSA], 2019), an annual assessment of mental health and substance use among people aged 12 and older in the United States, due to its national household sampling of individuals across the age periods of interest. Compared with MTF and YRBSS, NSDUH
tends to yield lower prevalence estimates but similar time trends and demographic correlates of adoles- cent substance use (SAMHSA, 2012). Unless oth- erwise noted, data in this section are from the most recent NSDUH in 2018. When referencing NSDUH estimates, “adolescents” refers to those aged 12 to 17 and “young adults” refers to those aged 18 to 25.
Prevalence of substance use. Figure 33.1 pro- vides the past-year prevalence of tobacco, alcohol, marijuana, and illicit drug use by age during adoles- cence and early adulthood. As defined in NSDUH, tobacco use includes cigarettes, smokeless tobacco, cigars, and pipe tobacco. Illicit drug use includes cocaine, crack, heroin, hallucinogens, inhalants, methamphetamine, and misused prescription drugs. The figure shows a general trend of increasing sub- stance use prevalence throughout adolescence and young adulthood.
Prevalence of substance use disorders. A smaller percentage meet clinical thresholds for abuse or dependence as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000). Prevalence of past-month nicotine dependence is 1% among adolescents and 8% among young adults. Preva- lence of past-year alcohol use disorder, cannabis use disorder, and substance use disorder for an illicit drug are 2%, 2%, and 1% among adolescents and 10%, 6%, and 3% among young adults, respec- tively. With the exception of nicotine dependence (most prevalent among individuals in their 30s), the prevalence of substance use disorders shows a sim- ilar age pattern to substance use, with prevalence highest among young adults as compared with other age groups.
Historical trends in substance use prevalence. From 2002 to 2018, past-year tobacco use steadily declined from 24% to 8% among adolescents and 55% to 37% among young adults, a major pub- lic health achievement. Past-year alcohol use also consistently declined among adolescents from 35% to 21%. Among young adults, alcohol use remained around 78% from 2002 to 2010 before declining to 73% in 2018. Past-year marijuana use fluctuated:
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Adolescent prevalence declined overall from 16% in 2002 to 13% in 2018, but young adult prevalence increased from 30% to 35%. Past-year illicit drug use remained relatively stable from 2015 to 2018, going from 9% to 8% among adolescents and 20% to 18% among young adults.
Somewhat similar trends have been documented in MTF. From 2002 to 2019, among adolescents, past-year prevalence of alcohol and illicit drug use declined while marijuana use remained rela- tively stable (Johnston et al., 2020). Among young adults aged 19 to 28 during this same time period, past-year alcohol use declined slightly, illicit drug use remained relatively stable but increased slightly, and marijuana use steadily increased (Schulenberg et al., 2020).
Prevalence by demographic characteristics. Substance use prevalence among young people varies by key demographics (e.g., sex, race/ethnicity, sexual minority status). In general, tobacco, alcohol, and marijuana use are more prevalent among male youth than female youth; however, some evidence
suggests slightly higher substance use prevalence among girls in early adolescence (P. Chen & Jacob- son, 2012; Evans-Polce et al., 2015). Considering differences by race/ethnicity, tobacco, alcohol, and marijuana use appear to be most prevalent among White youth; however, Latinx youth have slightly higher prevalence of alcohol and marijuana use in early adolescence (P. Chen & Jacobson, 2012; Evans-Polce et al., 2015). Compared with those who identify as heterosexual or straight, adolescents and young adults who identify as a sexual minority (i.e., gay, lesbian, or bisexual) have significantly higher prevalence of tobacco, alcohol, and illicit drug use (Marshal et al., 2008; Medley et al., 2016). However, these links vary by both sex (i.e., male or female) and bisexuality status (Marshal et al., 2008; Schuler et al., 2018).
Prevalence of other substance use. This chapter focuses broadly on tobacco, alcohol, marijuana, and illicit drug use. However, substance use landscapes shift historically with policy changes, emergence of new substances, prevalence changes in particular
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FIGURE 33.1. Prevalence of past-year substance use during adolescence and early adulthood, by age in years. Prevalence estimates are from the 2018 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2019). Illicit drug use does not include marijuana use.
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substances, and emergence of novel modes of administration. New research has focused on nic- otine vaping, high-intensity drinking (HID), and simultaneous alcohol and marijuana (SAM) use.
Recent increases in nicotine vaping (i.e., use of e-cigarettes or battery-powered devices) by young people have been among the largest for any sub- stance in the history of MTF. In 2019, past-year prevalence of nicotine vaping was 17% among eighth graders, 31% among 10th graders, 36% among 12th graders, and 25% among young adults aged 19 to 28. These rates were up 9%, 15%, 17%, and 11%, respectively, from 2017 (Johnston et al., 2020; Schulenberg et al., 2020). HID is com- monly defined as drinking at least twice the binge threshold. In the United States, about 10% of high school seniors and 19- to 20-year-olds consumed 10+ drinks in a row in the past 2 weeks, and an additional 4% to 5% drank 15+ drinks. Negative outcomes linked to HID include injury, risky sexual behavior, and alcohol poisoning (Patrick & Azar, 2018). The majority who use alcohol and marijuana do so at the same time (Subbaraman & Kerr, 2015), calling attention to SAM use. Prevalence is about 20% among young people (Patrick et al., 2017, 2019), and SAM use is linked to heavier substance use and increased consequences (Brière et al., 2011; Patrick et al., 2017).
Trajectories of Substance Use Across Adolescence and Early Adulthood Prevalence data within age groups provide useful snapshots of substance use at the population level, but understanding the progression of substance use within individuals is essential. Two broad approaches are used to characterize the course of substance use from adolescence through early adult- hood. Normative trajectory methods emphasize a typical trajectory based on population averages, and multiple trajectory approaches identify distinct sub- groups of people with similar patterns across time (Greenwood et al., 2019).
Normative substance use trajectory. While there are variations in timing and by substance, use generally begins in adolescence, increases into early adulthood, peaks, and then begins to decline
(Chassin et al., 2009; K. Chen & Kandel, 1995). This typical trajectory can be seen by examining mean prevalence of substance use by age, such as in Figure 33.1, and has been confirmed using longi- tudinal data (P. Chen & Jacobson, 2012). Develop- mental scientists posit that this normative trajectory reflects features of adolescence and early adulthood, including physical, cognitive, social, and contextual changes (Brown et al., 2008; Schulenberg et al., 2019). Role transitions in early adulthood, such as entering the workforce, marrying, and having children, are linked with substance use declines (Bachman et al., 2002; Chassin et al., 2009; Staff et al., 2010).
Multiple substance use trajectories. Normative trajectory approaches describe population averages but ignore varied substance use patterns among youth. By examining multiple, diverse trajectories of substance use, unique underlying risk factors and consequences can be identified. Synthesizing the empirical literature, Nelson et al. (2015) described common trajectories across adolescence and early adulthood for tobacco, alcohol, and marijuana use. For alcohol, four or five different trajectories were common. While variations existed, the majority of studies identified a stable low or no alcohol use trajectory, a stable heavy alcohol use trajectory, a gradually increasing trajectory, and a decreasing trajectory. Tobacco trajectories tended to be more varied across studies. Four main tobacco trajectories mirrored those found for alcohol use, but additional trajectories, such as sporadic, occasional use across age, were also identified. While less is known about marijuana use trajectories, research has identified a no/low use trajectory and an early onset/heavy use trajectory, along with other patterns. Several studies have found that young people who belong to a spe- cific trajectory for one substance are likely to have a similar pattern of use for other substances (Jackson et al., 2008; Nelson et al., 2015).
DEVELOPMENTAL ROOTS OF SUBSTANCE USE
Next, we focus on common developmental tran- sitions and contexts of adolescence and early
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adulthood that have implications for substance use. The timing, meaning, and impact of these transitions are profoundly influenced by cultural and immediate social contexts (Patton et al., 2016). Adolescents have disparate supports, opportunities, and challenges in interpersonal, educational, and career-related contexts. Prior research is limited by its primary focus on high-income countries (Hall et al., 2016), and there are major differences and inequities between and within countries, but we describe common developmental transitions next.
Pubertal Development A defining feature of adolescence is pubertal change, with rapid accelerations in growth, devel- opment of primary and secondary sex character- istics, and emergence of adultlike appearance and reproductive ability (Marshall, 1978; Susman & Dorn, 2013; see also Chapter 1, this volume). The age of pubertal onset has been steadily declining since at least the early 20th century (Eckert-Lind et al., 2020). On average, girls develop about 1.5 years earlier than boys, but by the end of secondary school, the majority of youth have reached full adult height and reproductive capacity. As adolescents increasingly look like young adults, their opportu- nities to experiment with substances may increase. This is especially true for earlier developers, whose parents grant them more autonomy and who may be welcomed into older peer groups (e.g., Bucci et al., 2020; Schelleman-Offermans et al., 2013). In general, physical changes and peer cultural norms combine to increase interest in and sensitivity to rewarding substance use effects (particularly social facilitation) and to diminish less desirable acute effects (e.g., sedation, hangover; Spear, 2014). Together, pubertal and other physical changes (see the following section on neurobiological changes) combine to increase the likelihood of experimenta- tion with substance use.
Neurobiological and Cognitive Changes and Risky Decision Making Many changes in brain structure and function (see Chapter 2, this volume) and in cognitive reasoning occur during adolescence and early adulthood. Some changes, especially those related to risk and
reward, have specific implications for substance use. First, developmental changes in the dopa- mine system (e.g., increases in dopamine receptor expression, neuron firing rate, number of neurons activated in anticipation of reward) make ado- lescents more sensitive to rewards, responsive to stress, emotional, and likely to engage in reward- and sensation-seeking behavior as compared with children or adults (Galván, 2013). These changes increase adolescents’ risk for substance use (Conrod & Nikolaou, 2016; Geier, 2013). Second, changes in the functioning of lower order subcortical regions of the brain (e.g., the limbic system) increase the likelihood of seeking novelty, reward, and stimu- lation. These changes typically occur several years prior to the complete maturation of the prefrontal cortex and other higher order cortical regions that regulate judgment, decision making, and impulse control (Galván, 2010; Padmanabhan et al., 2011). The asynchronous development of these brain regions, often referred to as the dual process or dual systems model, may help explain the substantial increase in substance use characteristic of adoles- cence and young adulthood (Casey et al., 2011; Somerville et al., 2010).
Third, in early adolescence, the brain’s sensitivity to social cues, especially social evaluation, increases (Guyer et al., 2012; Somerville, 2013). This change may partially explain why adolescents are more susceptible to peer influence (Casey & Jones, 2010; Steinberg, 2005), which can impact substance use. Fourth, in terms of decision making, adolescents take more risks than adults in both the laboratory and real world (Defoe et al., 2015; Steinberg, 2009). This may occur because adolescents and adults have different values and priorities, despite adolescents having the same basic cognitive abilities as adults by about age 15 (Casey et al., 2008; Steinberg, 2005). This could also be due to adolescents’ greater sensitivity to reward than punishment (Cauffman et al., 2010; Galván, 2013) and preference for immediate rather than delayed rewards (O’Brien et al., 2011; Scheres et al., 2006), both of which may play a role in peer-mediated substance use. Lastly, emotional and contextual factors may moderate risky decision making, including substance use, in adolescence. The likelihood of adolescents making
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risky decisions in calm conditions is similar to that of adults, but adolescents’ propensity for risk taking increases significantly when they are emotionally aroused (Figner & Weber, 2011; van Duijvenvoorde et al., 2010). Much of adolescents’ risk taking occurs in contexts in which they are emotionally aroused, unsupervised by adults, and with peers (Albert & Steinberg, 2011; Steinberg, 2014). In such contexts, adolescents may be more prone to making risky decisions (e.g., to accept an offer to use a substance) compared with when they are alone and/or not emotionally aroused (O’Brien et al., 2011; Smith et al., 2015). Together, neurobio- logical and neurocognitive changes during adoles- cence and early adulthood, as well as characteristics of young people’s decision-making processes during these periods, may increase some individuals’ pro- pensity to use substances.
Parent–Adolescent Relationships Adolescence and early adulthood bring significant change in family relationships (Laursen & Collins, 2009; Patton et al., 2016). In childhood, care- givers make most decisions, but the developing person progressively assumes more control and responsibility. Direct interaction time with family members decreases, and more time is spent alone, at school, with peers, and, later, at work (Laursen & Collins, 2009). Greater behavioral autonomy provides opportunities to experiment with risk behaviors, but people differ greatly in exploration of substance use.
Despite increased self-determination in adoles- cence, parents continue to facilitate their healthy development, including less substance use. The Oregon Social Learning Center (see Dishion & McMahon, 1998) identified effective family manage- ment as key. Family management includes positive parenting practices (e.g., praise and reinforcement), high-quality parent–adolescent relationships, and parental monitoring. Parents who have strong rela- tionships with their children and who use positive behavior management strategies reduce the impact of deviant peers (Dishion & McMahon, 1998). Dishion et al. (2004) proposed that premature adolescent autonomy increases risk for substance use. When active family management recedes too
early, the risk of deviant peer influences and sub- stance use is increased. Challenging behaviors in childhood (e.g., early, persistent antisocial behavior) and adolescence (e.g., evasive lying, delinquency) contribute to family management degradation (Clark et al., 2008). Fosco and LoBraico (2019) tested the premature adolescent autonomy model, using intensive daily data to document variability in family management. On days with more oppo- sitional child behavior and parent–adolescent conflict, parents engaged in less positive parenting, which in turn was linked with adolescents feeling less connected to parents. Importantly, adolescents whose feelings of connectedness fluctuated more when parents’ positive parenting wavered—charac- terized as fragile connectedness—were more likely to escalate their substance use.
Work on substance-specific parenting also supports the importance of parents in adolescence and young adulthood (e.g., Pinchevsky et al., 2012). Parents model substance use (e.g., attitudes, behavior) and inhibit adolescents’ use (e.g., through clear expectations, monitoring; Ennett et al., 2013; Maggs & Staff, 2018; Van Der Vorst et al., 2006). Parental influences are supported by prospective observational studies (e.g., Mattick et al., 2018) and randomized intervention trials (e.g., Kuntsche & Kuntsche, 2016). For example, adolescents whose parents provide alcohol or allow or ignore alco- hol use escalate faster to heavy drinking (Kaynak et al., 2014; Mattick et al., 2018; Staff & Maggs, 2020). Alcohol permissiveness may reflect beliefs that adolescent drinking is normative, inevita- ble, or desirable (Wilson et al., 2018). However, a systematic review concluded that parental rules against drinking alcohol predict lower odds of later risky drinking (Sharmin et al., 2017). Parents also influence substance use indirectly by shaping peer relationships and influences (Abar & Turrisi, 2008; Mounts, 2002).
Peer Relationships During adolescence, peer relations and sensitiv- ity to peer culture increase exposure to cultural norms and influences (Berkowitz, 2003; Steinberg, 2005). Traditional (e.g., films, TV, corporate ads) and newer media (e.g., social media, user-generated
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content, video sharing) introduce young people to prosubstance images from a young age (Patton et al., 2016). Peers are frequently assumed to be a primary cause of substance use, but research on their impact reveals complex links. Adolescents report strong similarities between their own and their friends’ substance use. However, as reviewed by Rulison et al. (2019), multiple mechanisms underlie these similarities: (a) selection (adolescents may choose friends who are similar in substance use attitudes and behaviors), (b) indirect peer influence (adolescents may model or conform to peer norms and behaviors), and (c) facilitation (peers may provide opportunities for use through social events, shared companions, or obtaining the substance). Direct peer pressure, however, is less common than believed by many adults.
How peers impact substance use also differs across types of relationships, that is, dyadic friend- ships, cliques and crowds, and social networks (Rulison et al., 2019). Traditional longitudinal research demonstrated that peer influences in friend dyads may be overestimated by cross-sectional sim- ilarity correlations, but more recent work modeling complex peer networks has shown important peer influences of broader social networks across an entire grade, school, or neighborhood (Rulison et al., 2019). Diffusion of innovations theory (Rogers, 1995) predicts that structural features of connec- tions, or social ties, between all adolescents in a net- work may contribute to diffusion of behaviors (e.g., vaping, heavy drinking, or not) across a network. A review by Montgomery et al. (2020) found evidence for similarities in peer networks due to both social selection and social influence. It is important to note that this process involves selection and influ- ence both to not use and to use substances.
Finally, social status within networks is import- ant, with more popular adolescents tending to engage in more substance use (Montgomery et al., 2020). Whether the underlying mechanisms are due to popularity leading to more substance use (e.g., more party invites), substance use leading to greater popularity, popular adolescents feeling more conformity pressures, or some other process is not clear. Some evidence supports each process (Rulison et al., 2019). Further complexity arises
when considering teens outside a social network as well as differences between substances. For exam- ple, socially isolated adolescents are more likely to smoke cigarettes but less likely to use alcohol (Osgood et al., 2014; Rulison et al., 2019).
Romantic and Sexual Relationships Major qualitative transformations occur during this age period in sexual interests, feelings, and identity. Most but not all youth initiate romantic relation- ships and sexual behaviors (Boislard et al., 2016). Pubertal changes provide the biological foundation for these behaviors, but cognitive, emotional, inter- personal, and social/cultural factors also shape these changes. Brooks-Gunn and Paikoff (1993) identi- fied four developmental challenges for adolescents regarding sexuality: becoming comfortable with their maturing bodies, accepting feelings of sexual arousal as normal and healthy, understanding that shared sexual behaviors should be mutually vol- untary, and understanding and practicing safe sex. These challenges are new, intense, and both private and relational, and they involve complex feelings and confusing interactions with others (Boislard et al., 2016; Russell & Fish, 2019; Tolman & McClel- land, 2011). Therefore, they remain salient well into young adulthood.
Alcohol use can easily be paired with romantic and sexual experiences. Desires to meet or spend time with potential partners may motivate participa- tion in social contexts where substances are avail- able (e.g., peer homes, parties, bars). Sexual scripts shape behaviors (Garcia et al., 2019), and positive expectancies about alcohol’s social and sexual enhancement effects can increase drinking motiva- tions (Patrick et al., 2015). Drinking can also reduce inhibitions or provide an excuse for unplanned or risky behaviors (Garcia et al., 2019).
Just as transitions into new intimate relation- ships co-occur with greater substance use, romantic breakups are also a time of greater use in young adults (Fleming et al., 2018). In prior generations, transitions into stable cohabiting and marital rela- tionships predicted reduced substance use (Bach- man et al., 2002; Maggs et al., 2012). However, as recent cohorts remain in education longer and take on traditional adult roles (e.g., worker, spouse,
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parent) later than past cohorts (Furstenberg, 2010), lifestyles linked with heavier substance use may be extended (Jager et al., 2015), increasing the period of risk, with possible harmful effects on health. In summary, substance use and sexual relationships are social behaviors and are related in complex ways. For adolescents and young adults, desires for partnership may motivate substance use both to facilitate new relationships and to cope with their loss when they end.
School Transitions and Paid Work Many school systems involve two or three major transitions during adolescence: the transition from primary to secondary school (around age 11), between secondary institutions (e.g., middle to high school, around age 14), and from secondary to postsecondary education and/or the workforce (around age 18; see Chapter 17, this volume). Each transition brings many changes, which can be challenging (Benner, 2011). The first two transitions are more universal and compulsory, yet discrepancies between adolescents’ develop- mental needs and school contexts increase across these major transitions (Eccles & Roeser, 2009). These gaps may increase stress as responsibilities and expectations for success accelerate (Gottfred- son & Hussong, 2011; Jackson & Schulenberg, 2013). The transition out of secondary education often signals major changes, including increases in autonomy, especially if the individual moves out of the parental home (Schulenberg & Maggs, 2002; Settersten & Ray, 2010). Youth who successfully navigate and adapt to these school transitions are typically at lower risk for substance use and related problem behaviors than those who struggle in navigating such transitions (Schulenberg & Maggs, 2002). However, adolescents also seek out peers and contexts that encourage or inhibit substance use and other risk behaviors (Patrick et al., 2016; Samek et al., 2016).
The relationship between substance use and academic performance and achievement is com- plex. Numerous studies have found that individ- uals who drop out of high school or college use substances more frequently and in greater amounts than those who do not (Fleming et al., 2012;
Townsend et al., 2007). Although some research suggests that academic performance is negatively linked with substance use, neither the direction nor the causality of this link is clear. Importantly, shared risk factors and selection effects may con- found these simple correlations (Chassin et al., 2009; White & Hingson, 2013). More evidence suggests that academic outcomes affect substance use than indicates that substance use affects aca- demic outcomes, especially for the majority who finish high school (Bachman et al., 2008; Schulen- berg et al., 2014).
Paid work has become normative during middle and late adolescence in the United States (see Chapter 18, this volume); the majority of high school and full-time postsecondary students, and nearly all part-time postsecondary students, work during the school year (Bureau of Labor Statistics & U.S. Department of Labor, 2019; Staff et al., 2009). Considerable research has documented an association between greater substance use and working longer hours (i.e., more than 20 hours per week) during the school year (Bachman et al., 2011; Monahan et al., 2011; Steinberg et al., 1993), yet the direction and causality of this rela- tionship remain unclear (Staff et al., 2009). This ambiguity may partially be due to the complex- ity of the relationship; findings indicate that the association between paid work and substance use is moderated by the quality of work experiences (Staff & Uggen, 2003) and sociodemographic character- istics, such as socioeconomic status, race/ethnicity, and sex (Staff et al., 2009).
Similar challenges exist after adolescence: Edu- cational and occupational pathways during early adulthood are associated with social class and have become increasingly varied in timing and sequence (Côté & Bynner, 2008; Settersten & Ray, 2010). Staff et al. (2010) found that family-related social role changes (e.g., getting married, having chil- dren) during early adulthood were more predictive of changes in substance use than were work or school changes. As with part-time paid work, some evidence suggests that the quality of employment moderates associations between full-time work status and substance use, as high-quality, stable employment appears to be associated with lower
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levels of substance use and other problem behaviors (Laub & Sampson, 2003; Uggen, 1999).
NEGATIVE CONSEQUENCES OF SUBSTANCE USE
Given that adolescence and early adulthood are marked by major developmental transitions that set the stage for later life health and well-being, it is important to identify possible harms to healthy development. Although substance use causes many acute negative consequences (e.g., hangover, miss- ing school, injury), a developmental perspective also draws attention to how substance use might impact long-term development and functioning.
A key difficulty in identifying long-term conse- quences of substance use is determining the extent to which associations are causal. Notably, engaging in any, heavy, or chronic substance use is not ran- dom. Substance use patterns and their correlates are both preceded and predicted by individual char- acteristics, such as childhood disruptive disorders (Krueger et al., 2002), personality traits (Littlefield & Sher, 2016), and neurobiological characteristics (Gray & Squeglia, 2018). These key risk factors are difficult to assess, especially prospectively from childhood, and thus are not available in many lon- gitudinal studies. Yet these are important potential confounders of links between substance use and its harms. A systematic review by McCambridge et al. (2011) concluded that although many studies document links between adolescent alcohol use and adult mental health, physical health, and social outcomes, causal evidence with appropriate controls for confounding was lacking. This issue complicates developmental substance use research, but analytic techniques that allow for within-person compar- isons, such as individual growth modeling, are increasingly used to control for potential confounds.
Chassin et al. (2009) described four mechanisms that could potentially explain associations between adolescent substance use and negative outcomes in adulthood. First, adolescent substance use may result in enduring neurobiological damage to mechanisms of reward and self-regulation. Second, pharmacological effects may impair performance on key developmental tasks (e.g., studying, job
performance). Third, substance use that develops into dependence may interfere with adult psycho- social functioning later (e.g., work, family roles). Lastly, if substance use during adolescence and early adulthood interferes with emerging developmental competency and the completion of developmental tasks, it may affect later psychosocial outcomes.
Extant research shows that adolescent substance use, especially of alcohol and marijuana, affects the structure and functioning of the developing brain, which may result in persistent negative functional consequences (Gray & Squeglia, 2018). For instance, fMRI studies indicate that initiation of heavy alcohol use during adolescence, as opposed to early adulthood, is associated with increased brain activation over time on visual working mem- ory and inhibition tests, suggesting that adolescent drinkers process information less efficiently and maturely than abstainers (Squeglia et al., 2012; Wetherill et al., 2013). More distally, adolescent and young adult substance use trajectories are consistent predictors of consequences later in life (Schulenberg et al., 2019). For example, young people who delay substance use initiation until late adolescence or young adulthood are less likely to exhibit heavy use and substance use disorders in adulthood (Kellam & Anthony, 1998; Spoth et al., 2009). Many studies have also documented links between substance use and long-term health (e.g., Hall et al., 2016), psy- chosocial functioning (e.g., Staff et al., 2010), and achievement (e.g., Maggs et al., 2015). However, as noted earlier, causality is difficult to pin down, as substance use is associated with many other risk factors. Identifying specific behaviors and patterns of substance use that are the most harmful, for whom, and in what situations should be a goal of future research.
LOOKING BACK AND LOOKING FORWARD
As reviewed here, substance use is intrinsically linked with adolescent and young adult develop- ment. Much is known about the role and func- tion of substance use in young people’s lives, its cultural embeddedness, and its potential acute and long-term harms. At the time of writing,
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surrounded by worldwide disruption due to COVID-19 and increasing inequities in health, education, resources, and future prospects, it is difficult to predict the future. Few things can ever be asserted with absolute certainty, but given cross-species and historical continuity, we suggest that the transition from childhood to adulthood will endure. Transformations with puberty and neurological development will occur. Parents, peers, and romantic interests will continue to be foundational interpersonal contexts. Adolescents will prepare for and transition to adult productivity. We also suggest it is likely, though by no means universal, that varied psychoactive substances will continue to be available, used, and enjoyed; that substance use patterns will be inextricably mixed with adolescent and young adult development; and that some people’s substance use will cause acute and/or lifelong harm.
At least two sets of broad societal changes may be starting to change the questions researchers ask and the ways they do research. First, dramatic technological advances are adding both to chal- lenges and to capabilities for public health and psychological research: New drug delivery systems and products entice new users toward experimen- tation and dependence (e.g., electronic nicotine delivery systems). Ambulatory and passive mea- sures transform data collection possibilities (e.g., wearables, GPS tracking). Statistical innovations introduce novel modeling and prevention strate- gies (e.g., just-in-time interventions). In response to these developments, data collection and inter- vention implementation may increasingly use smartphone applications that allow scientists to connect with participants multiple times per day in natural settings. Other technology-driven data collection techniques may allow reliable, noninva- sive, real-time biometric measurement of use and intoxication to move beyond relying on self-reports completed later.
Second, policy changes, such as the legalization of marijuana, decriminalization of other previously illicit substances (e.g., psilocybin mushrooms) in some places, and privatization of alcohol and mari- juana sales, are creating both new challenges to and opportunities for substance use research. Research
is needed to understand the effects of such policy changes on use, as well as on norms, consequences, and social behavior. Examination of whether these impacts differentially affect different demographic groups, such as adolescents versus adults, is also needed.
The transition to adulthood is especially chal- lenging in turbulent economic and political times and even more so for communities and individu- als with fewer resources. Technological advances and policy changes over the next decade or two will ensure no shortage of research questions for scientists to study. In a context of many important problems facing young people, substance use will remain an important contributor to global disease burden and, as such, deserves continued research focus and passion.
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