State Prevalence and Ranks of Adolescent Substance Use: Implications for Cancer Prevention

Jennifer L. Moss, PhD; Benmei Liu, PhD; Li Zhu, PhD


Prev Chronic Dis. 2018;15(5):e69 

In This Article

Abstract and Introduction


Introduction This study statistically ranked states' performance on adolescent substance use related to cancer risk (past-month cigarette smoking, binge alcohol drinking, and marijuana use).

Methods Data came from 69,200 adolescent participants (50 states and the District of Columbia) in the National Survey on Drug Use and Health (NSDUH) and 450,050 adolescent participants (47 states) in the Youth Risk Behavior Surveillance System (YRBSS). Adolescents were aged 14 to 17 years. For 2011–2015, we estimated and ranked states' prevalence of adolescent substance use. We calculated the ranks' 95% confidence intervals (CIs) using a Monte Carlo method with 100,000 simulations. Spearman correlations examined consistency of ranks.

Results Across states, the prevalence of cigarette smoking was 4.5% to 14.3% in NSDUH and 4.7% to 18.5% in YRBSS. Utah had the lowest prevalence (NSDUH: rank = 51 [95% CI, 47–51]; YRBSS: rank = 47 [95% CI, 46–47]), and states' ranks across surveys were correlated (r = 0.66, P < .001). The prevalence of binge alcohol drinking was 5.9% to 14.3% (NSDUH) and 7.1% to 21.7% (YRBSS). Utah had the lowest prevalence (NSDUH: rank = 50 [95% CI, 40–51]; YRBSS: rank = 47 [95% CI, 47–47]), but ranks across surveys were weakly correlated (r = 0.38, P = .01). The prevalence of marijuana use was 6.3% to 18.7% (NSDUH) and 8.2% to 27.1% (YRBSS). Utah had the lowest prevalence of marijuana use (NSDUH: rank = 50 [95% CI = 33–51]; YRBSS: rank= 46 [95% CI, 46–46]), and ranks across surveys were correlated (r = 0.70, P < .001). Wide CIs for states ranked in the middle of each distribution obscured statistical differences among them.

Conclusion Variability emerged across adolescent substance use behaviors and surveys (perhaps because of administration differences). Most states showed statistically equivalent performance on adolescent substance use. Adolescents in all states would benefit from efforts to reduce substance use, to prevent against lifelong morbidity.


Substance use causes avoidable illness and death, including from cancer.[1] Smoking tobacco causes lung, liver, and colorectal cancers, among others.[2] Moderate to heavy alcohol consumption is associated with oropharyngeal, colorectal, and pancreatic cancers.[3] Emerging evidence suggests a positive association between marijuana use and prostate and cervical cancer.[4] Despite these risks, substance use is common: 60 million Americans smoke, 14 million are alcohol-dependent, and 14 million use illicit drugs (including marijuana).[1]

Reducing substance use among adolescents is particularly important for preventing cancer. First, lifelong substance use often begins in adolescence.[5,6] For example, 88% of adult daily smokers began smoking before age 18.[7] Second, adolescence is a vulnerable period when people are particularly sensitive to substance use.[2] Understanding adolescent substance use is therefore crucial to reducing the risk of related cancers.

Monitoring adolescent substance use, however, is challenging. Some adolescents may underreport use because of social desirability or fear of legal consequences[8] and others may overreport use to earn social cache from their peers.[8] Studies comparing self-report to biometric measures of substance use have indicated that self-report measures have fair validity, with some adolescents underreporting and some overreporting use.[8,9] However, quantifying the degree of uncertainty in estimates of adolescent substance use in surveillance surveys is important for leveraging these estimates for research and intervention purposes. Given that some public health efforts attempt to target adolescents in high-risk geographic areas, the ability to reliably identify which states have the highest or lowest prevalence of substance use may be called into question for several reasons: different surveillance surveys may identify different states; states likely rank differently across behaviors; and statistical uncertainty may undermine strong conclusions about differences across states. Understanding the extent of this problem has implications for surveillance research, specifically for cancer prevention.

We compared and ranked state estimates of past-month cigarette smoking, binge alcohol drinking, and marijuana use among adolescents from 2 population-based surveys: the National Survey of Drug Use and Health (NSDUH) and the Youth Risk Behavior Surveillance System (YRBSS). Both surveys collect substance use data for youths using cross-sectional, multistage probability sampling design, but each survey has its own strengths.[10] A major strength of NSDUH is its ability to support estimates for all 50 states and the District of Columbia, and the data are collected every year. A major strength of YRBSS is its large state-level sample size; however, the survey is conducted every other year and not every state participates in the study or achieves adequate response rates. Comparison of the 2 surveys would highlight the consistencies or differences in rankings across different surveys. Calculation of confidence intervals (CIs) around ranks, often overlooked in ranking studies,[11,12] allowed us to statistically evaluate consistencies and differences in state ranks within and across surveys and behaviors, and explore implications for cancer prevention.