Drinking, Bingeing and Toking More Popular Than Smoking Among Teens in 2014

Teen smoking deservedly gets a great deal of attention from the media and public policymakers, but one government survey shows that teens consume alcohol and marijuana at far higher rates than cigarettes.

The National Surveys on Drug Use and Health (NSDUH), which I discussed last week (here), provide intriguing insights into use of licit and illicit products.

At left are 2014 NSDUH estimates of the numbers – and percentages by age – of Americans using cigarettes, smokeless tobacco, alcohol and marijuana in the past month. (Binge drinking is defined as consuming five or more drinks within two hours)  There were nearly 56 million smokers, 8.6 million smokeless tobacco users, 22.5 million marijuana users and a whopping 140 million drinkers.  There were actually more binge drinkers (61 million) than smokers. 

The following table shows the number of teens (12-17 years) and young adults (18-20 years) who used these substances in 2014.

Numbers (millions) of Teens and Young Adults Who Were Past-Month Smokers, Smokeless Users, Drinkers, Binge Drinkers and Marijuana Users in 2014
	Teens (12-17 yrs)	Young Adults (18-20 yrs	Total
Smokers	1.23	3.24	4.47
Smokeless Users	0.50	0.66	1.16
Drinkers	2.80	5.88	8.68
Binge Drinkers	1.53	3.74	5.27
Marijuana Users	1.85	2.77	4.62

There were some 1.2 million past-month smokers under 18, and about half a million underage smokeless users.  These numbers pale in comparison to those for alcohol.  There were 2.8 million drinkers under 18, and another 5.9 million between 18 and 20.  There were more underage binge drinkers (1.5 million) and marijuana users (1.85 million) than smokers.  The totals for marijuana, drinking and binge drinking are all greater than smoking.

Teenage smoking must be prevented, but teen abuse of alcohol and marijuana also requires attention.

U.S. Can’t Decide How Many Adults Use Smokeless – 8.1 Million or 5.1 Million?

Federal officials routinely obfuscate on the subject of smokeless tobacco, and particularly on the number of smokeless users in the U.S.

The newest numbers are reported by Dr. Rachel Lipari and Mr. Struther Van Horn of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). They say, “In 2014, an estimated 8.7 million people aged 12 or older used smokeless tobacco in the past month.” (available here)  Their finding is based on data from the National Survey on Drug Use and Health (NSDUH).

That number included teens (Age 12-17 years).  When including only adults (18 and older), the NSDUH estimate is 8.1 million in 2014, which contrasts with a 2015 CDC-supported National Health Interview Survey (NHIS) adults-only estimate of 5.1 million. The 59% higher NSDUH number probably results from the use of different definitions.  NSDUH collects information on past-30 day use, whereas current users in NHIS is every day or some days.

The primary conclusion in the Lipari/Van Horn report is that “Smokeless tobacco is not a healthy alternative to cigarette smoking.”  This is a non sequitur, as the NSDUH survey includes no information on health. 

The government inconsistency also extends to smoking numbers, as I discussed previously (here, here and here).  The NSDUH estimate of adult U.S. smokers for 2014 was 55.8 million, about 40% higher than the NHIS estimate of 40 million for that year.

It is time for federal officials to acknowledge the gross inconsistency of the government’s tobacco use estimates. In all likelihood, the higher NSDUH estimates, which reflect the fact that Americans use tobacco products more irregularly than every day or some days, are closer to reality than those based on the NHIS.

Smoking May Harm Mental Health

Research has documented a strong link between smoking and various mental health disorders, including anxiety, depression, schizophrenia and bipolar disorder.  The CDC advises that about 20% of American adults had some form of mental illness in 2009-2011, and the smoking rate for that group was 36%, in contrast to 21% for all others (here).

There is certainly an association, but there are four distinct possibilities with respect to causality:

·       Mental health problems cause people to smoke.

·       Smoking causes mental health problems.

·       Both pathways exist.

·       Neither pathway exists.

My economist colleague Dr. Nantaporn Plurphanswat is the lead author of an innovative analysis that identifies a potential causal pathway for mental illness and smoking; the work appears in the American Journal of Health Behavior (abstract here).  Our co-author is University of Illinois professor Dr. Robert Kaestner.  We used data from people in almost all states participating in the federal Behavioral Risk Factor Surveillance System (BRFSS) from 2000 to 2010.  BRFSS collected information on smoking and asked participants “…for how many days during the past 30 days was your mental health [which includes stress, depression, and problems with emotions] not good?”

Recognizing that traditional approaches cannot identify a causal pathway between smoking and mental illness, Drs. Plurphanswat and Kaestner employed an instrumental variable approach, in which variation in smoking at the state level is strongly associated with cigarette excise taxes, but the excise taxes are completely unrelated to outcomes like mental health.  The IV analysis provides information on whether smoking leads to mental health problems, or vice versa.

Our results indicate that smoking may harm mental health: it is significantly associated with 14 or more days of poor mental health.  Most of the effect due to smoking is from large increases in the number of mentally unhealthy days and not by small increases among many smokers. 

The BRFSS data cannot tell us whether smoking is a form of self-medication practiced by those who suffer from specific mental health disorders.  However, our analysis confirms that smoking may contribute to anxiety, depression and emotional distress.  Thus, policies that reduce smoking may have a positive spill-over effect in improving mental health.