National Survey on Drug Use and Health NSDUH DATA REVIEW September 2017 Risk and Protective Factors and Estimates of Substance Use Initiation: Results from the 2016 National Survey on Drug Use and Health Authors SAMHSA: Rachel N. Lipari and Rebecca D. Ahrnsbrak; RTI International: Michael R. Pemberton and Jeremy D. Porter Abstract Background. Risk factors are typically associated with an increased more than a year ago and continued to use in the past year, were less likelihood of substance use, and protective factors are typically likely than people who last used more than a year ago or who never associated with a decreased likelihood of substance use. Efforts to used to perceive great risk from using those substances. prevent substance use generally aim to reduce the influence of risk The illicit drugs with the largest number of recent initiates aged factors and to enhance the effectiveness of protective factors. One 12 or older in 2016 were marijuana (2.6 million new users), major goal of substance use prevention programs is to prevent or prescription pain relievers (2.1 million new misusers), prescription delay the initiation of substance use (i.e., first use). tranquilizers (1.4 million new misusers), prescription stimulants Methods. This report presents results from the 2016 National (1.4 million new misusers), hallucinogens (1.2 million new users), Survey on Drug Use and Health (NSDUH) for people aged 12 and cocaine (1.1 million new users). The number of people in or older regarding the perceived harmfulness of using cigarettes, 2016 who initiated marijuana use in the past year was higher than alcohol, and specific illicit drugs as well as the perceived availability the numbers in 2002 through 2008, but the numbers of recent of substances. Estimates are presented for specific age groups. marijuana use initiates were similar in 2009 to 2016. For cocaine, Estimates of the perceived great risk of harm associated with the the number of recent initiates in 2016 was higher than the numbers use of marijuana, cocaine, alcohol, and cigarettes also are presented in 2008 to 2014 and had risen to levels that were comparable with according to whether people initiated use of these substances in the numbers in the early 2000s. Similar numbers of people in 2015 the past year. In addition, the report presents estimates for youth- and 2016 also were recent initiates of cocaine use. For heroin, the specific protective factors, such as perceptions about parents strongly number of past year initiates in 2016 was similar to the numbers of disapproving of youth substance use. Finally, this report presents the recent initiates in 2007 to 2015. estimated numbers of individuals who initiated substance use in the Among people aged 12 or older in 2016, there were 4.6 million past year and the average age at first use among people who initiated new users of alcohol, 1.8 million people who tried a cigarette for use in the past year (i.e., past year initiates). Statistically significant the first time in the past year, and 1.2 million people who first differences are noted for estimates in the report. used smokeless tobacco in the past year. The number of people in Results. Although more than 4 out of 5 people aged 12 or older 2016 who smoked part or all of a cigarette for the first time in the in 2016 perceived great risk of harm from weekly use of cocaine, past year was lower than the numbers in 2004 to 2014, but it was heroin, or lysergic acid diethylamide (LSD), only about one third similar to the number in 2015. of people perceived great risk of harm from weekly marijuana Conclusions. Findings from NSDUH on risk perceptions and use. An estimated 68.3 percent of people also perceived great risk initiation of substance use are useful to the Substance Abuse and from having four or five drinks of alcohol nearly every day, and Mental Health Services Administration for gauging the overall 72.8 percent perceived great risk from smoking one or more packs effectiveness of prevention efforts or policies on a broad national of cigarettes per day. Perceptions of risk from substance use varied level. However, these NSDUH data are not intended to be used across age groups. For example, about 2 out of 5 youths aged 12 to evaluate the effectiveness of individual prevention programs or to 17 perceived great risk from weekly marijuana use compared policies. Because NSDUH is a cross-sectional study, its data also with about 1 in 6 young adults aged 18 to 25. For marijuana and cannot be used to track changes in respondents' perceptions of risk cocaine, people who had never used these substances were most of harm from substance use over their lifetime and directly relate likely to perceive great risk of harm from using the substance. For these changes to specific chronological events, such as the initiation cigarettes and alcohol, people who used in the past year, including of substance use. those who initiated use in the past year and those who initiated use Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 2 Introduction initiation of substance use in the United States. Estimates for initiation include the number of individuals who used a Substance use is a major public health problem in the United substance for the first time in the past year and the average age States. In 2016, for example, 10.6 percent of people aged at first use among people who initiated use in the past year. 12 years or older used illicit drugs in the past month, and Comprehensive 2016 NSDUH detailed tables that show 7.5 percent had a substance use disorder in the past year.1 additional substance use-related outcomes, including data Nevertheless, many individuals do not engage in substance for various subpopulations covered in NSDUH, are available use. Whether someone engages in substance use is associated separately at https://www.samhsa.gov/data/.9 with several risk factors that are typically correlated with an increased likelihood of substance use (e.g., perception of low risk of harm from using a substance, easy availability of Survey Background substances) and protective factors that are typically associated NSDUH is an annual survey of the civilian, with a decreased likelihood of substance use (e.g., exposure noninstitutionalized population of the United States aged to prevention messages).2 Risk and protective factors 12 years old or older.10 The survey is sponsored by the include variables that reflect different domains of influence, Substance Abuse and Mental Health Services Administration including the individual, family, peer, school, community, (SAMHSA) within the U.S. Department of Health and and society.3,4,5 Interventions to prevent substance use are Human Services (HHS). The survey covers residents of commonly designed to reduce the influence of risk factors households and individuals in noninstitutional group and enhance the effectiveness of protective factors. One quarters (e.g., shelters, boarding houses, college dormitories, goal of substance use prevention programs is to prevent migratory workers' camps, halfway houses). The survey or delay the initiation (i.e., first use) of substance use. excludes people with no fixed address (e.g., homeless people Multiple studies have found associations between early not in shelters), military personnel on active duty, and initiation of alcohol or illicit drug use (e.g., in adolescence) residents of institutional group quarters, such as jails, nursing and an increased likelihood of developing substance use homes, mental institutions, and long-term care hospitals. disorders, although there are competing explanations for the underlying reasons for the associations.6,7,8 Information NSDUH employs a stratified multistage area probability sample that is designed to be representative of both the nation on trends in initiation also can provide information on the as a whole and for each of the 50 states and the District of long-term effectiveness of programs or policies as a whole Columbia. The 2016 NSDUH annual target sample size of to prevent substance use (i.e., but not the effectiveness of 67,500 interviews was distributed across three age groups, individual programs or policies). with 25 percent allocated to adolescents aged 12 to 17, The National Survey on Drug Use and Health (NSDUH) 25 percent allocated to young adults aged 18 to 25, and provides information on risk and protective factors that 50 percent allocated to adults aged 26 or older. From 2002 are related to the likelihood that individuals will initiate or through 2013, the NSDUH sample was allocated equally continue to engage in substance use. The survey also collects across these three age groups. Although the sample design information on the initiation of use of illicit drugs, alcohol, changed in 2014, NSDUH had the same total target sample and tobacco in the past year, as well as information on the size per year of 67,500 interviews between 2002 and 2016.11 age at first use of these substances. NSDUH is a face-to-face household interview survey that is conducted in two phases: the screening phase and the This report summarizes findings from the 2016 interview phase. The interviewer conducts a screening of the National Survey on Drug Use and Health (NSDUH) sampled household with an adult resident (aged 18 or older) for substance use prevention issues and the initiation of in order to determine whether zero, one, or two residents substance use in the United States. aged 12 or older should be selected for the interview.12 NSDUH collects data using audio computer-assisted self-interviewing (ACASI) in which respondents read or listen This report contains the first findings from the 2016 NSDUH to the questions on headphones, then enter their answers for substance use prevention issues, including the perceived directly into a NSDUH laptop computer. ACASI is designed risk of harm from substance use and the perceived availability to encourage accurate reporting of information by providing of substances. The report also presents findings for the Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 3 respondents with a highly private and confidential mode for presented in the report compare 2016 estimates with estimates responding to questions about illicit drug use, mental health, from 3 or more prior years. Most trend analyses focus on and other sensitive behaviors. NSDUH also uses computer- percentages because the percentages take into account any assisted personal interviewing (CAPI) in which interviewers changes in the size of the total population and facilitate the read less sensitive questions to respondents and enter the comparison of estimates across years;17 however, trend analyses respondents' answers into a NSDUH laptop computer. for the initiation of substance use focus on the number of people who initiated substance use in the past year rather than on percentages. Therefore, care should be taken in interpreting This report is based on data from increases over time in the estimated number of past year 67,942 completed interviews from 2016 NSDUH initiates because some of these increases could reflect growth respondents aged 12 or older. in the size of the population. In 2016, screening was completed at 135,188 addresses, Trends are presented in this report for and 67,942 completed interviews were obtained, including 2016 estimates that remained comparable with 17,109 interviews from adolescents aged 12 to 17 and estimates from prior years. 50,833 interviews from adults aged 18 or older. Weighted response rates for household screening and for interviewing were 77.9 and 68.4 percent, respectively, for an overall Most 2016 estimates in this report are presented for response rate of 53.3 percent for people aged 12 or older. individuals aged 12 or older, adolescents aged 12 to 17, The weighted interview response rates were 77.0 percent for young adults aged 18 to 25, and adults aged 26 or older. adolescents and 67.6 percent for adults.13 Further details However, some estimates are presented only for adolescents about the 2016 NSDUH design and methods can be found aged 12 to 17 because questions on the perceptions of on the web at https://www.samhsa.gov/data/.14 parental disapproval of substance use, youths' disapproval of peers' substance use, and exposure to substance use prevention messages were asked only of adolescents. Data Presentation and Interpretation All estimates (e.g., percentages and numbers) presented One of NSDUH's strengths is the stability in the sample and in the report are derived from NSDUH survey data that survey designs. This stability allows for the examination of are subject to sampling errors. The estimates have met the trends across time. However, the benefit of using NSDUH criteria for statistical reliability. Estimates that do not meet data to assess trends has to be balanced with the periodic these criteria for reliability have been suppressed and are not need to revise NSDUH content to address changes in shown.18 Where trends are presented, this report compares society and emerging issues. Consequently, the NSDUH estimates in 2016 with estimates in each of the years from questionnaire underwent a partial redesign in 2015 to 2002 to 2015. Statistical tests also have been conducted for improve the quality of the NSDUH data and to address the comparisons that appear in the text of the report. Statistically changing needs of policymakers and researchers with regard significant differences are described using terms such as to substance use and mental health issues. New baselines "higher," "lower," "increased," or "decreased." Statements were started in 2015 for estimates that were affected by use terms such as "similar," "remained steady," or "stable" changes to the 2015 NSDUH questionnaire. when a difference is not statistically significant. Analyses of Trends are presented in this report for estimates from the 2016 long-term trends in this report summarize whether the 2016 NSDUH that are assumed to have remained comparable estimates are generally different from or similar to estimates with estimates from 2015 and prior years.15,16 These include in most or all previous years,19 while minimizing discussion comparisons of 2016 estimates with those from prior years for of anomalous differences between any 2 years that can occur youths' perceptions of parental disapproval of youth substance due to these estimates being based on samples.20,21 Graphics use, youths' disapproval of peers' substance use, youths' and tables contain estimates that support the statements in exposure to substance use prevention messages, and the this report, and supplementary tables of estimates (including initiation of the use of substances that were not affected by the standard errors) are included in Appendix A. 2015 questionnaire changes. When new baselines started in 2015, estimates are discussed only for 2016. All trends that are Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 4 Perceived Risk from Substance Use heroin (94.1 percent) than for cocaine (87.1 percent), LSD (83.9 percent), or marijuana (34.0 percent). One factor that can influence whether individuals will use tobacco, alcohol, or illicit drugs is the extent to which they Perceived Risk from Marijuana Use believe these substances might cause them harm. In 2016, In 2016, 27.7 percent of individuals aged 12 or older perceived NSDUH respondents were asked how much they thought great risk of harm from smoking marijuana once a month (i.e., people risk harming themselves physically and in other ways monthly marijuana use), and 34.0 percent perceived great risk when they use various substances in certain amounts or from smoking marijuana once or twice a week (i.e., weekly frequencies. Response choices for these items were "great risk," marijuana use) (Figure 1). Perceptions of risk varied by age, with "moderate risk," "slight risk," or "no risk." For many of these young adults aged 18 to 25 being less likely than adolescents substances, respondents were asked about their perceived risk aged 12 to 17 or adults aged 26 or older to perceive great risk of harm from using substances once a month (i.e., monthly from smoking marijuana monthly or weekly (Figure 2). use) or once or twice a week (i.e., weekly use). As mentioned previously, only estimates from 2016 are presented for In 2016, 27.1 percent of adolescents aged 12 to 17 perceived perceived risk because a new baseline was established in 2015, great risk of harm from monthly marijuana use, and about 2 and trends are presented only when the 2016 estimates can be in 5 adolescents perceived great risk from weekly marijuana compared with estimates from 3 or more prior years. use (40.0 percent) (Figure 2). An estimated 13.5 percent of young adults aged 18 to 25 in 2016 perceived great risk from Figure 1 presents the percentages of people aged 12 or older monthly marijuana use, and 17.2 percent perceived great risk in 2016 who perceived great risk of harm from each of the from weekly marijuana use. Among adults aged 26 or older, substance use measures. However, caution should be used 30.2 percent indicated there was a great risk from smoking when comparing perceptions of risk across certain substances because of variations in the content of questions.22 For marijuana monthly, and 36.1 percent indicated there was a great risk from smoking marijuana weekly. substances where the same quantity and frequency of use were used, comparing risk perceptions across substances becomes Perceived Risk from Cocaine Use more straightforward. For example, respondents were asked about the perceived risk of harm associated with any use of In 2016, most individuals aged 12 or older perceived great the following drugs once or twice a week: marijuana, cocaine, risk of harm from using cocaine either once a month or heroin, and lysergic acid diethylamide (LSD). Therefore, once or twice a week (71.8 and 87.1 percent, respectively) it is appropriate to note that in 2016, the percentage of (Figure 1). Perceptions of risk varied by age, with adolescents individuals aged 12 or older who perceived great risk of harm aged 12 to 17 being less likely than young adults aged 18 to from using these drugs once or twice a week was higher for 25 or adults aged 26 or older to perceive great risk from using Figure 1. Perceived Great Risk from Substance Use among People Aged 12 or Older: Percentages, 2016 Smoking Marijuana Once a Month 27.7 Smoking Marijuana Once or Twice a Week 34.0 Using Cocaine Once a Month 71.8 Using Cocaine Once or Twice a Week 87.1 Trying Heroin Once or Twice 85.6 Using Heroin Once or Twice a Week 94.1 Trying LSD Once or Twice 69.5 Using LSD Once or Twice a Week 83.9 Having 5+ Drinks of Alcohol Once or Twice a Week 44.4 Having 4 or 5 Drinks of Alcohol Nearly Every Day 68.3 Smoking One or More Packs of Cigarettes per Day 72.8 0 20 40 60 80 100 Percent Perceived Great Risk LSD = lysergic acid diethylamide. Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 5 cocaine either monthly or weekly (Figure 3). Additional to 25 or adults aged 26 or older to perceive great risk from data on age groups that can be found in the 2016 detailed trying heroin once or twice or using it weekly (Figure 4). As tables indicate that the percentage of adolescents who with risk perceptions for cocaine use, younger adolescents perceived great risk from monthly cocaine use ranged from aged 12 or 13 were less likely than older adolescents to 46.8 percent of adolescents aged 12 or 13 to 65.3 percent perceive great risk from heroin use (e.g., 53.3 percent of of those aged 16 or 17.9 The percentage of adolescents who 12 or 13 year olds perceived great risk from trying heroin perceived great risk from weekly cocaine use ranged from once or twice vs. 76.4 percent of 16 or 17 year olds).9 Thus, 73.9 percent of those aged 12 or 13 to 85.4 percent of those the lower likelihood of adolescents than adults to perceive aged 16 or 17. Therefore, the lower likelihood of adolescents great risk of harm from heroin use may be attributable to a than adults to perceive great risk of harm from cocaine use general lack of knowledge about heroin among adolescents, may reflect a general lack of knowledge about cocaine among especially among younger adolescents. adolescents, especially among younger adolescents. Figure 3. Perceived Great Risk from Using Cocaine among People In 2016, more than half of adolescents perceived great risk Aged 12 or Older, by Age Group: Percentages, 2016 of harm from monthly cocaine use (56.4 percent), and about 100 4 out of 5 adolescents (80.6 percent) perceived great risk 88.4+,# 83.6+ 80.6 from weekly cocaine use (Figure 3). In 2016, 64.8 percent k 80 74.7+,# s of young adults aged 18 to 25 perceived great risk from at Ri 64.8+ monthly cocaine use, and 83.6 percent perceived great risk Gre 60 56.4 d e from weekly cocaine use. About 3 out of 4 adults aged 26 or v ei c older in 2016 indicated there was a great risk from monthly Per 40 nt cocaine use (74.7 percent), and 88.4 percent indicated there e c er 20 was a great risk from weekly cocaine use. P 0 Perceived Risk from Heroin Use Using Cocaine Using Cocaine Once a Month Once or Twice a Week In 2016, most individuals aged 12 or older perceived great 12 to 17 18 to 25 26 or Older risk of harm from trying heroin once or twice (85.6 percent) or from using heroin weekly (94.1 percent) (Figure 1). + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically significant at the .05 level. Perceptions of risk varied by age group, with adolescents # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically aged 12 to 17 being less likely than young adults aged 18 significant at the .05 level. Figure 2. Perceived Great Risk from Smoking Marijuana among Figure 4. Perceived Great Risk from Heroin Use among People Aged People Aged 12 or Older, by Age Group: Percentages, 2016 12 or Older, by Age Group: Percentages, 2016 50 100 93.5+ 95.4+,# 88.4+,# 40.0 83.0+ 83.4 Percent Perceived Great Risk 12340000 27.1 13.5+ 30.2+,# 17.2+ 36.1+,# Percent Perceived Great Risk 24680000 65.6 0 0 Smoking Marijuana Smoking Marijuana Trying Heroin Using Heroin Once a Month Once or Twice a Week Once or Twice Once or Twice a Week 12 to 17 18 to 25 26 or Older 12 to 17 18 to 25 26 or Older + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically significant at the .05 level. significant at the .05 level. # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically significant at the .05 level. significant at the .05 level. Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 6 The lower perceptions of the risk of harm from heroin use Perceived Risk from Binge Alcohol Use among adolescents relative to older age groups were most In 2016, about 2 out of 3 individuals aged 12 or older evident in the percentage who perceived great risk of harm perceived great risk of harm from having four or five drinks from trying heroin once or twice. In 2016, 65.6 percent of of alcohol nearly every day (68.3 percent), and 44.4 percent adolescents aged 12 to 17 perceived great risk from trying perceived great risk from having five or more drinks of alcohol heroin once or twice (Figure 4). In comparison, 83.0 percent of once or twice a week (Figure 1). For brevity, these levels of young adults aged 18 to 25 and 88.4 percent of adults aged 26 alcohol consumption are subsequently referred to as "binge or older in 2016 perceived great risk from trying heroin once or alcohol use" or "binge drinking" in this section.23 Thus, twice. An estimated 83.4 percent of adolescents perceived great despite the well-documented health problems and increased risk from weekly heroin use compared with 93.5 percent of risk for serious injuries that are associated with excessive young adults and 95.4 percent of adults aged 26 or older. alcohol use,24 less than half of those aged 12 or older in 2016 perceived great risk from weekly binge alcohol use. Perceived Risk from LSD Use Perceptions of risk from binge alcohol use varied by age in In 2016, most individuals aged 12 or older perceived great 2016. Percentages of people who perceived great risk of harm risk of harm from trying LSD once or twice (69.5 percent) from binge drinking once or twice a week were lowest among or from using LSD weekly (83.9 percent) (Figure 1). young adults aged 18 to 25 (37.1 percent), followed by Perceptions of risk varied by age, with adolescents aged 12 adolescents aged 12 to 17 (44.1 percent), then by adults aged to 17 and young adults aged 18 to 25 being less likely than 26 or older (45.6 percent) (Figure 6). Similarly, young adults adults aged 26 or older to perceive great risk from trying were least likely to perceive great risk from binge drinking LSD once or twice or using it weekly (Figure 5). nearly every day (62.3 percent), followed by adolescents In 2016, about half of adolescents (50.4 percent) perceived great (65.5 percent), then by adults aged 26 or older (69.6 percent). risk of harm from trying LSD once or twice, and 70.5 percent Perceived Risk from Smoking a Pack or More of perceived great risk of harm from weekly LSD use (Figure 5). Cigarettes Daily About half of young adults aged 18 to 25 (54.5 percent) perceived great risk of harm from trying LSD once or twice, and about 3 In 2016, 72.8 percent of individuals aged 12 or older out of 4 (74.4 percent) perceived great risk of harm from weekly perceived great risk of harm from smoking one or more LSD use. Among adults aged 26 or older, about 3 out of 4 packs of cigarettes per day (Figure 1). Perceptions of risk (74.2 percent) perceived great risk from trying LSD once or twice, varied by age, with adults aged 26 or older being more likely and 87.0 percent perceived great risk from using LSD weekly. than adolescents aged 12 to 17 and young adults aged 18 to Figure 5. Perceived Great Risk from LSD Use among People Aged 12 Figure 6. Perceived Great Risk from Alcohol Use among People Aged or Older, by Age Group: Percentages, 2016 12 or Older, by Age Group: Percentages, 2016 100 80 87.0+,# 69.6+,# Percent Perceived Great Risk 24680000 50.4 54.5+ 74.2+,# 70.5 74.4+ Percent Perceived Great Risk 234567000000 44.1 37.1+ 45.6+,# 65.5 62.3+ 10 0 0 Trying LSD Using LSD Having 5+ Drinks of Alcohol Having 4 or 5 Drinks of Alcohol Once or Twice Once or Twice a Week Once or Twice a Week Nearly Every Day 12 to 17 18 to 25 26 or Older 12 to 17 18 to 25 26 or Older LSD = lysergic acid diethylamide. + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically significant at the .05 level. significant at the .05 level. # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically significant at the .05 level. significant at the .05 level. Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 7 25 to perceive great risk from smoking one or more packs of to get marijuana if they wanted some (Figure 8). About 1 in cigarettes per day (Figure 7). Nevertheless, about two thirds 12 adolescents (8.7 percent) indicated that heroin would be or more of people in each age group perceived great risk easily obtainable. About 1 in 8 reported that it would be easy from smoking a pack or more of cigarettes per day. to get LSD or cocaine (12.0 and 12.6 percent, respectively). About 2 out of 3 adolescents and young adults perceived great Nearly 3 out of 4 young adults aged 18 to 25 in 2016 risk from smoking one or more packs of cigarettes per day (69.3 reported that it would be easy for them to get marijuana if and 68.6 percent, respectively) (Figure 7). Nearly three fourths they wanted some (74.0 percent) (Figure 8). About 1 in 7 of adults aged 26 or older (73.9 percent) perceived great risk young adults (15.9 percent) reported that it would be easy from smoking one or more packs of cigarettes per day. for them to get heroin. About 1 in 5 young adults reported that they could easily get LSD (19.5 percent). About one fourth of young adults reported that they could easily get Perceived Availability of Specific Drugs cocaine (26.6 percent). Many studies have demonstrated that the availability of In 2016, more than half of adults aged 26 or older drugs (i.e., ease of obtaining drugs) is associated with drug (58.3 percent) believed it would be easy for them to get initiation and use.2,3,25 Perceptions of drug availability are marijuana if they wanted some (Figure 8). Nearly 1 in 5 also important because they may affect how prevention adults aged 26 or older (18.9 percent) reported that it would programs are structured, such as in states with laws related to be easy for them to get heroin. About 1 in 8 adults in this marijuana use that can directly affect availability.26 age group (13.3 percent) reported that it would be easy for In 2016, NSDUH respondents were asked how easy it would them to get LSD if they wanted some. Nearly one fourth of be for them to obtain substances if they wanted some; they adults aged 26 or older believed it would be easy for them to were given the response options of "very easy," "fairly easy," get cocaine (23.1 percent). "fairly difficult," "very difficult," or "probably impossible." This section provides estimates for people in different age Being Approached by Someone Selling Drugs groups who thought it would be "fairly easy" or "very easy" to obtain the substance. However, respondents could report that Another way to assess an individual's risk of drug initiation they did not know how easy or difficult it would be to obtain or use is to determine if an individual has been actively a substance, or they could refuse to answer the question; these solicited by people selling drugs. NSDUH respondents respondents were excluded from the analysis.27 are asked if they had been approached by someone selling drugs in the past month. In 2016, young adults aged 18 In 2016, almost half (44.7 percent) of youths aged 12 to 17 reported that it would be fairly easy or very easy for them Figure 8. Perceived Availability of Substances among People Aged 12 or Older, by Age Group: Percentages, 2016 Figure 7. Perceived Great Risk from Smoking One or More Packs of Cigarettes per Day among People Aged 12 or Older, by Age Group: 80 74.0+ 12 to 17 Percentages, 2016 70 18 to 25 80 73.9+,# bility 60 58.3+,# 26 or Older 70 69.3 68.6 vaila 50 44.7 A k d Perceived Great Ris 34560000 Percent Perceive 12340000 12.626.6+23.1+,# 8.7 15.9+18.9+,# 12.019.5+13.3+,# nt ce 20 0 Per Marijuana Cocaine Heroin LSD 10 LSD = lysergic acid diethylamide. 0 + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically 12 to 17 18 to 25 26 or Older significant at the .05 level. + Difference between this estimate and the estimate for youths aged 12 to 17 is statistically # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically significant at the .05 level. significant at the .05 level. # Difference between this estimate and the estimate for young adults aged 18 to 25 is statistically Note: Percentages refer to reports that it would be fairly easy or very easy to obtain the substance. significant at the .05 level. Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 8 to 25 were more likely than adolescents aged 12 to 17 to percentage was similar to the percentages in most years from indicate that they had been approached in the past month by 2010 to 2015, but it was somewhat higher than the percentages someone selling drugs (13.3 vs. 11.0 percent) (Table A.1B in 2002 to 2009, which ranged from 88.5 to 90.3 percent. in Appendix A). Adults aged 26 or older were less likely than In 2016, most youths (94.0 percent) reported that their adolescents or young adults to be approached by someone parents would strongly disapprove of them smoking one or selling drugs in the past month (3.8 percent). more packs of cigarettes per day (Figure 9). This percentage was similar to the percentages in 2013 to 2015, but it was Youth Perceptions of Parental Disapproval of higher than the percentages in 2002 to 2012, which ranged Youth Substance Use from 89.5 to 93.2 percent. Adolescents' perceptions of the level of parental disapproval Figure 9. Youths Felt That Parents Would Strongly Disapprove of youth substance use have been associated with the of Substance Use Behaviors among Youths Aged 12 to 17: initiation of substance use and substance use in general Percentages, 2002-2016 among adolescents.2 In 2016, NSDUH respondents aged 100 12 to 17 were asked whether their parents would "neither al v approve nor disapprove," "somewhat disapprove," or pro 80 p "strongly disapprove" if they used different substances. This sa Di section presents percentages of youths who believed that al 60 nt their parents would "strongly disapprove" of them using are P specific substances. ed 40 Smoking One or More Packs of Cigarettes per Day v ei Trying Marijuana Once or Twice c Most adolescents in 2016 believed that their parents would Per 20 Using Marijuana Once a Month or More strongly disapprove of them trying marijuana once or twice, ent Having 1 or 2 Drinks of Alcohol Nearly Every Day c using marijuana monthly, drinking alcohol nearly every Per 0 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 day, or smoking one or more packs of cigarettes per day (Figure 9). The percentages of youths who believed that + Difference between this estimate and the 2016 estimate is statistically significant at the .05 level. their parents would strongly disapprove of these behaviors Figure 9 Table. Youths Felt That Parents Would Strongly Disapprove increased between 2002 and 2016 for cigarette smoking and of Substance Use Behaviors among Youths Aged 12 to 17: Percentages, 2002-2016 alcohol use. However, the percentage of adolescents who believed that their parents would disapprove of them trying Perceived Parental 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 Disapproval or using marijuana declined over this period. Smoking One or More Packs of Cigarettes 89.5+89.8+90.6+91.1+91.4+92.1+92.4+92.6+92.6+93.2+93.1+93.5 93.8 93.6 94.0 In 2016, 86.5 percent of youths reported that their parents per Day would strongly disapprove of them trying marijuana once Trying Marijuana Once 89.1+89.4+89.8+90.2+90.4+91.0+90.7+90.5+89.6+89.3+89.3+88.4+87.5+87.6+86.5 or Twice or twice, and 89.0 percent reported that their parents would Using Marijuana Once a 92.0+92.2+93.0+92.9+93.1+93.3+93.1+93.0+91.9+91.6+91.3+90.6+90.0+89.8 89.0 Month or More strongly disapprove of them using marijuana once a month Having 1 or 2 Drinks or more (Figure 9). The percentage of youths in 2016 of Alcohol Nearly 89.0+88.5+89.0+88.9+89.6+89.6+89.7+90.3+90.5 90.5+90.5 90.7 90.6 90.9 91.2 Every Day who reported that their parents would strongly disapprove + Difference between this estimate and the 2016 estimate is statistically significant at the .05 level. of them trying marijuana was slightly lower than the percentages in each year from 2002 to 2015, which ranged from 87.5 to 91.0 percent. The percentage of youths in 2016 Youth Disapproval of Peers’ Substance Use who reported that their parents would strongly disapprove Research has also shown associations between adolescents' of them using marijuana once a month or more was also attitudes about their peers' substance use and their initiation slightly lower than the percentages in 2002 to 2014, which of substance use.2 In 2016, NSDUH respondents aged 12 ranged from 90.0 to 93.3 percent, but it was similar to the to 17 were asked whether they would "neither approve nor 2015 percentage (89.8 percent). disapprove," "somewhat disapprove," or "strongly disapprove" Most youths in 2016 (91.2 percent) reported that their parents if someone their age used different substances. This section would strongly disapprove of them having one or two drinks presents percentages of youths who "somewhat disapproved" or of an alcoholic beverage nearly every day (Figure 9). This "strongly disapproved" of specific substance use by their peers. Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 9 Most adolescents strongly or somewhat disapproved of their printed information about drugs or alcohol outside of regular peers using marijuana monthly, drinking alcohol nearly classes such as in a special assembly). Adolescents also are asked every day, or smoking one or more packs of cigarettes per whether they had seen or heard drug or alcohol use prevention day. The percentages of youths who strongly or somewhat messages in the past year from sources outside of school and disapproved of these behaviors increased between 2002 and whether they have participated in the past 12 months in an 2016 for cigarette and alcohol use. alcohol, tobacco, or drug prevention program outside of school. In 2016, 90.6 percent of youths strongly or somewhat In 2016, 71.8 percent of youths aged 12 to 17 who were disapproved of their peers having one or two drinks enrolled in school in the past year reported having seen or of an alcoholic beverage nearly every day (Table A.3B heard drug or alcohol use prevention messages at school in Appendix A). This percentage was higher than the (Figure 10). This percentage was lower than the percentages percentages in 2002 to 2014, but it was similar to the in 2002 to 2013, but it was similar to the percentages in percentage in 2015. Nevertheless, about 85 percent or more 2014 and 2015. In 2002, for example, 78.8 percent of of adolescents in most of the years between 2002 and 2016 adolescents who were enrolled in school reported exposure to strongly or somewhat disapproved of their peers having one substance use prevention messages at school. or two drinks of an alcoholic beverage nearly every day. In 2016, 72.7 percent of youths aged 12 to 17 reported having About 4 out of 5 youths in 2016 (80.2 percent) strongly or seen or heard drug or alcohol use prevention messages in somewhat disapproved of their peers using marijuana once the past year from sources outside of school, such as posters, a month or more (Table A.3B). The percentage of youths pamphlets, the radio, or television (Figure 10). The percentage who disapproved of their peers using marijuana once a in 2016 was lower than the percentages in 2002 to 2012, but month or more was lower in 2016 than in 2004 to 2010, it was similar to the percentages in 2013 to 2015. but it was similar to the percentages in 2002, 2003, and In 2016, about 1 in 9 youths aged 12 to 17 (11.4 percent) 2011 to 2015. Despite these differences, about 80 percent or reported that they had participated in alcohol, tobacco, or drug more of adolescents in most of the years between 2002 and use prevention programs outside of school in the past year 2016 strongly or somewhat disapproved of their peers using marijuana once a month or more. Figure 10. Past Year Exposure to Substance Use Prevention In 2016, 93.6 percent of youths strongly or somewhat Messages and Programs among Youths Aged 12 to 17: disapproved of their peers smoking one or more packs of Percentages, 2002-2016 cigarettes per day (Table A.3B). This percentage was higher s 100 than the percentages in 2002 to 2014, but it was similar to e g a the percentage in 2015. ess 80 M n o Youth Exposure to Substance Use Prevention Preventist Year 60 Messages d to n Pa 40 ei s Substance use prevention programs are designed to discourage o p Ex 20 Prevention Messages Outside of School children and adolescents from starting to use tobacco, alcohol, nt e Prevention Messages at School or illicit drugs by reducing the influence of risk factors for erc P 0 substance use and increasing the influence of protective 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 factors.28,29 Substance use prevention messages and programs are + Difference between this estimate and the 2016 estimate is statistically significant at the .05 level. provided through schools, the media, and other sources. Since Figure 10 Table. Past Year Exposure to Substance Use Prevention Messages 2002, NSDUH has included a series of questions about youth and Programs among Youths Aged 12 to 17: Percentages, 2002-2016 exposure to substance use prevention messages from different Exposure 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 sources. Adolescents are asked whether they have been exposed Prevention to prevention messages in the past 12 months through school Messages 83.2+83.6+83.0+81.1+79.3+77.8+77.9+76.9+75.9+75.1+75.9+72.6 72.9 73.3 72.7 Outside of sources (i.e., special classes about drugs or alcohol in school; School films, lectures, discussions, or printed information about drugs Prevention Messages 78.8+78.1+78.2+77.9+76.9+75.8+76.1+75.2+75.7+74.6+75.0+73.5+73.0 72.7 71.8 or alcohol in regular school classes such as health or physical at School education; or films, lectures, discussions, or distribution of + Difference between this estimate and the 2016 estimate is statistically significant at the .05 level. Risk and Protective Factors and Estimates of Substance Use Initiation: | Results from the 2016 National Survey on Drug Use and Health September 2017 10 (Table A.4B in Appendix A). This estimate was similar to of past year initiates for these substances in 2016 are not the percentages in 2004 to 2015, but it was lower than the comparable with estimates prior to 2015. percentages in 2002 and 2003. Nevertheless, in any given This section also presents the average age at first use (or misuse year since 2002, the majority of youths did not participate in for prescription drugs) among recent initiates for specific prevention programs outside of school in the past year. substances. The estimates are limited to recent initiates because NSDUH respondents who started using (or misusing) a Initiation of Substance Use substance recently would be expected to have less difficulty The 2016 NSDUH had two key measures related to remembering how old they were when they first used it substance use initiation (i.e., the first use of a particular compared with respondents whose first use occurred several substance). One of the measures examined the age at which years before the interview. Although the numbers of initiates are a person first used a given substance (age at first use). The shown for individuals aged 12 or older and by age group, the other key measure identified whether a person started using average ages at first use (or first misuse) in this report are limited or misusing a substance for the first time over the past year to all past year initiates aged 12 to 49 to avoid the influence of (recent initiate).30 The estimates of the number of substance extreme values on the averages. For example, a small number of use initiates or prescription drug misuse initiates in this people who started using (or misusing) a substance at very late report are limited to recent initiates.31 Recent initiates were ages could heavily influence the average age at first use (or first defined as substance users or prescription drug misusers misuse) among all initiates and cause instability in the estimated who reported that they first used or misused, respectively, a average. Because the survey was revised in 2015, estimates particular substance within 12 months of the date of their of the average age at first misuse for the prescription drug interview.32,33 Prescription drug misuse is defined as use in categories and estimates of the average age at first use among any way not directed by a doctor, including use without methamphetamine, hallucinogen, inhalant, and smokeless a prescription of one's own; use in greater amounts, more tobacco initiates are presented only for 2016. often, or longer than told to take a drug; or use in any other Figure 11 provides an overview of the numbers of past year way not directed by a doctor. More information about the initiates in 2016 for the majority of substances that methods for measuring and estimating the initiation of are discussed in this section. The illicit drugs with the substance use and prescription drug misuse in NSDUH can be found on the web in Section B.4.2 of the 2016 NSDUH's Figure 11. Numbers of Past Year Initiates of Substances among methodological summary and definitions report.14 People Aged 12 or Older: 2016 Unlike previous sections, this section focuses on the numbers Marijuana 2.6 Million of people who were recent initiates (e.g., the number Rx Pain Relievers 2.1 Million of people aged 12 or older who were recent initiates of Rx Tranquilizers 1.4 Million marijuana use) rather than on percentages. Information on Rx Stimulants 1.4 Million Hallucinogens 1.2 Million the number of recent initiates can be useful to policymakers Cocaine 1.1 Million and program planners for anticipating future needs for LSD 844,000 health services both in the short term and in the longer term. Ecstasy 757,000 For example, the number of people who have initiated use Inhalants 526,000 of substances such as heroin could signal future needs for Rx Sedatives 294,000 emergency medical services, treatment for infectious diseases Methamphetamine 192,000 such as hepatitis, or substance use treatment. However, care Heroin 170,000 4.6 Million Alcohol should be taken in interpreting increases over time in the Cigarettes 1.8 Million estimated number of past year initiates because some of these Smokeless Tobacco 1.2 Million increases could reflect growth in the size of the population 0 1 2 3 4 5 over time. Because of changes to the 2015 NSDUH Past Year Initiates questionnaire, initiation estimates for prescription drugs LSD = lysergic acid diethylamide; Rx = prescription. (i.e., pain relievers, tranquilizers, stimulants, and sedatives), Note: Estimates for prescription pain relievers, prescription tranquilizers, prescription stimulants, methamphetamine, hallucinogens, inhalants, and smokeless and prescription sedatives are for the initiation of misuse. Misuse is defined as use in any way not directed by a doctor, including use without a prescription of one’s own; use in greater amounts, more tobacco are shown only for 2016; estimates for the numbers often, or longer than told to take a drug; or use in any other way not directed by a doctor.