Research

JAMA Pediatrics | Original Investigation

Assessment of Changes in Alcohol and Marijuana Abstinence,

Co-Use, and Use Disorders Among US Young Adults
From 2002 to 2018
Sean Esteban McCabe, PhD; Brooke J. Arterberry, PhD; Kara Dickinson; Rebecca J. Evans-Polce, PhD;
Jason A. Ford, PhD; Jennie E. Ryan, PhD; Ty S. Schepis, PhD

Supplemental content
IMPORTANCE Recent information on the trends in past-year alcohol abstinence and marijuana
abstinence, co-use of alcohol and marijuana, alcohol use disorder, and marijuana use disorder
among US young adults is limited.

OBJECTIVES To assess national changes over time in past-year alcohol and marijuana
abstinence, co-use, alcohol use disorder, and marijuana use disorder among US young adults
as a function of college status (2002-2018) and identify the covariates associated with
abstinence, co-use, and marijuana use disorder in more recent cohorts (2015-2018).

DESIGN, SETTING, AND PARTICIPANTS This study examined cross-sectional survey data
collected in US households annually between 2002 and 2018 as part of the National Survey
on Drug Use and Health. The survey used an independent, multistage area probability sample
for all states to produce nationally representative estimates. The sample included 182 722
US young adults aged 18 to 22 years. The weighted screening and weighted full interview
response rates were consistently above 80% and 70%, respectively.

MAIN OUTCOMES AND MEASURES Measures included past-year abstinence, alcohol use,
marijuana use, co-use, alcohol use disorder, marijuana use disorder, prescription drug use,
prescription drug misuse, prescription drug use disorder, and other drug use disorders based
on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.

RESULTS The weighted sample comprised 51.1% males. Between 2002 and 2018, there was
an annual increase in past-year alcohol abstinence among young adults (college students:
0.54%; 95% CI, 0.44%-0.64%; non–college students: 0.33%; 95% CI, 0.24%-0.43%).
There was an annual increase in marijuana use from 2002 to 2018 (college: 0.46%; 95% CI,
0.37%-0.55%; non-college: 0.49%; 95% CI, 0.40%-0.59%) without an increase in marijuana
use disorder for all young adults. Past-year alcohol use disorder decreased annually (college:
0.66%; 95% CI, 0.60%-0.74%; non-college: 0.61%; 95% CI, 0.55%-0.69%), while co-use
of alcohol and marijuana increased annually between 2002 and 2018 among all young adults
(college: 0.60%; 95% CI, 0.51%-0.68%; non-college: 0.56%; 95% CI, 0.48%-0.63%). Young
adults who reported co-use of alcohol and marijuana or met criteria for alcohol use disorder
and/or marijuana use disorder accounted for 82.9% of young adults with prescription drug
use disorder and 85.1% of those with illicit drug use disorder. More than three-fourths of
those with both alcohol use disorder and marijuana use disorder reported past-year
prescription drug use (78.2%) and illicit drug use (77.7%); 62.2% reported prescription
drug misuse.

CONCLUSIONS AND RELEVANCE The findings of this study suggest that US colleges and
communities should create and maintain supportive resources for young adults as the
substance use landscape changes, specifically as alcohol abstinence, marijuana use, and
co-use increase. Interventions for polysubstance use, alcohol use disorder, and marijuana
use disorder may provide valuable opportunities for clinicians to screen for prescription
Author Affiliations: Author
drug misuse.
affiliations are listed at the end of this
article.
Corresponding Author: Sean
Esteban McCabe, PhD, Center for the
Study of Drugs, Alcohol, Smoking and
Health, University of Michigan School
of Nursing, 400 North Ingalls
JAMA Pediatr. doi:10.1001/jamapediatrics.2020.3352 Building, Ste 2241A, Ann Arbor, MI
Published online October 12, 2020. 48109 (plius@umich.edu).

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 Research Original Investigation Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults
S
ubstance use disorders (SUDs) are most prevalent among
US young adults compared with other US age groups,
and 2 of the most common SUDs are alcohol use disor-
der and marijuana use disorder.1-3 Recently, marijuana use has
increased and alcohol use has decreased among US young
adults, but trends in the co-use of these substances remain
largely unknown.3,4 Consequences associated with alcohol,
marijuana, and other drug use during young adulthood in-
clude injury, SUDs, depressive symptoms, overdose, and
death.5-7
The transition from adolescence to young adulthood is an
important developmental period for studying substance use
behaviors because emerging adults often experience less
parental monitoring and make increasingly independent
decisions.8,9 Although the association between college atten-
dance and substance use differs based on the substance used,
the college environment can also directly affect substance
use behavior, acting as either a protective influence or a risk
factor.4,9 Research has shown that binge drinking, prescrip-
tion stimulant misuse, and alcohol use disorder are more preva-
lent among college students than non–college students.4,10-12
In contrast, marijuana use, prescription opioid misuse, pre-
scription sedative or tranquilizer misuse, and multiple SUDs
are more prevalent among non–college students.4,12-15
Earlier studies examining changes over time in substance
use behaviors among young adults focused largely on indi-
vidual substances used by US college students.16-18 One con-
cerning change between 1993 and 2001 was an increased risk
for developing alcohol use disorder as a result of increased fre-
quency of binge drinking.16 There was also an increase in past-
year alcohol abstinence over the same period, from 16.4% in 1993
to 19.3% in 2001, suggesting a polarization of drinking
behavior.17 The polarization of increased alcohol abstinence and
high-risk drinking over the same period among college
students occurred alongside a decrease in low-risk drinking.17
This change suggests a need for a more nuanced examination
of long-term changes associated with alcohol involvement
among US young adults. In addition, increases in marijuana use
were found in US young adults between 1993 and 2017,4,18,19 es-
pecially among non–college students, with daily marijuana use
reaching an all-time high of 13.2% in 2016.4 Although national
data often focus on individual substances, it is useful to also ex-
amine changes in polysubstance use and multiple SUDs.20-22
Polysubstance use and multiple SUDs have been shown to be
more persistent in their course and challenging to treat.20-22
Despite the increased focus on substance use changes
among US adolescents,21,23 there has been a dearth of re-
search examining trends in abstinence from substance use
among US young adults, as well as little research differentiat-
ing these changes by educational status over the past 2 de-
cades. The aim of the present study was to use nationally rep-
resentative data collected from 17 cohorts of US young adults
aged 18 to 22 years, with 2 objectives. The first was to identify
the long-term changes (2002-2018) in past-year abstinence,
nondisordered substance use (ie, substance use that does not
meet Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition [DSM-IV] criteria for SUD), and SUD based on
DSM-IV criteria of alcohol use disorder, marijuana use disor-
E2 JAMA Pediatrics Published online October 12, 2020 (Reprinted)
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Key Points
Question Have rates of alcohol abstinence and marijuana
abstinence, co-use, and use disorders changed in US young adults
from 2002 to 2018 as a function of college status?
Findings A nationally representative cross-sectional survey
conducted annually of 182 722 US young adults found that alcohol
abstinence, marijuana use, and co-use of alcohol and marijuana all
increased between 2002 and 2018. These findings were apparent
for both college students and non–college students.
Meaning The findings of this study suggest that colleges and
communities should create and maintain supportive resources in
response to the recent changes in the US young adult substance
use landscape, accounting for increases in alcohol abstinence,
marijuana use, and co-use of alcohol and marijuana.
der, and both alcohol use disorder and marijuana use disorder
(ie, disordered co-use) as a function of college status. The sec-
ond objective was to examine the prevalence of past-year
prescription drug use, prescription drug misuse, illicit drug
use, and SUDs based on DSM-IV criteria as a function of alco-
hol and marijuana use among US young adults in recent
cohorts (2015-2018).
Methods
This study examined cross-sectional data collected annually
in household surveys between 2002 and 2018 as part of the
National Survey on Drug Use and Health (NSDUH). The NSDUH
used an independent, multistage area probability sample for
all states to produce nationally representative data. Inter-
views began with audio computer-assisted self-interviewing
questions on sensitive variables such as substance use. Audio
computer-assisted self-interviewing was used to ensure pri-
vacy and promote honest reporting and data completeness.
Response rates for the NSDUH were consistently above 80%
for the weighted screening and above 70% for the weighted
full interview. Details regarding NSDUH methods are avail-
able elsewhere.24,25 The present study was exempt from re-
view and need for informed patient consent by the Texas State
University Institutional Review Board. This study followed
the Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) reporting guideline for cross-
sectional studies.26
Measures
College status among respondents aged 18 to 22 years was cat-
egorized as college student and non–college student. Respon-
dents were classified as college students if they reported that
they were in their first through fourth year at a college or uni-
versity and were either full- or part-time students (ranging from
44.5% to 51.0% between 2002 and 2018). Respondents were
classified as non–college students if their current enrollment
status was known and they were not classified as a full- or part-
time college student (ranging from 38.9% to 44.9% between
2002 and 2018). Respondents who were on breaks in the school
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 Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults
year were considered enrolled if they intended to return to col-
lege or university when the break ended. Respondents who
were in high school, graduated college, or had an unknown
current college enrollment status were considered another
cohort and excluded from most analyses (ranging from 9.4%
to 11.5% between 2002 and 2018).
Alcohol, marijuana, and other substance use included past-
year alcohol use, past-year marijuana use, past-year other illicit
drug use, and past-year prescription drug use/misuse. Past-year
alcohol use, past-year marijuana use, and past-year other illicit
drug use, including heroin, cocaine, hallucinogens, inhalants,
and methamphetamine, were all assessed from 2002 to 2018.
Prescription drug use and misuse were assessed from 2015 to
2018 by asking respondents a series of questions regarding the
use and misuse of prescription opioids, stimulants, and sedatives/
tranquilizers in the past 12 months. The time frame for prescrip-
tion drug use and misuse differed from other substances owing
to wording changes in the NSDUH made in 2015. From 2015 to
2018, the NSDUH defined prescription drug misuse as “use with-
out a prescription of one's own; use in greater amounts, more
often, or longer than told to take a drug; or use in any other way
not directed by a doctor.”25
Substance use disorders were assessed using past-year
DSM-IV alcohol use disorder and marijuana use disorder crite-
ria. Similar measures of other drug use disorders were as-
sessed. Earlier studies reported that these measures have good
reliability and validity.27,28 Nondisordered alcohol use and non-
disordered marijuana use were defined as alcohol use and mari-
juana use that did not meet DSM-IV criteria for alcohol use
disorder or marijuana use disorder. For combined alcohol
and marijuana past-year use, a 7-level variable was created:
(1) abstinence from both, (2) nondisordered alcohol use, (3) non-
disordered marijuana use, (4) nondisordered co-use (ie, use of
both alcohol and marijuana without meeting disorder crite-
ria), (5) alcohol use disorder only, (6) marijuana use disorder only,
and (7) both alcohol use disorder and marijuana use disorder.
Sociodemographic variables and other controls included
sex, race/ethnicity, sexual orientation, income, population den-
sity, religion, and physical health (self-reported health, body
mass index, and hospitalizations). Mental health variables in-
cluded mental health treatment, major depression, psycho-
logical distress, disability, and suicidal ideation.
Statistical Analysis
All analyses used Stata, version 16.0 (StataCorp, LLC), using
svy commands to account for the NSDUH complex survey de-
sign. The NSDUH data were weighted, clustered on primary
sampling units, and stratified. The Taylor series approxima-
tion was used, with adjusted degrees of freedom, to create ro-
bust variance estimates. Initially, weighted cross-tabulations
estimated the annual prevalence of sex, race/ethnicity, and col-
lege enrollment status. Potential change over the study pe-
riod was evaluated using binary logistic regression for sex and
multinomial logistic regression for race/ethnicity and college
enrollment status, with estimates of linearized annual change
(via the Stata margins command, which calculates predicted
trend slope, adjusting for average covariate values over the
study period) for analyses significantly associated with year.
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Original Investigation Research
Analyses with subpopulations (eg, college students and non–
college students) used the subpop option. For all analyses ex-
amining annual change and all regression analyses thereaf-
ter, we adjusted for changing sociodemographic variables from
2002 to 2018. Over these 17 years, the US population changed
in terms of race/ethnicity and college status (eTable 1 in the
Supplement), making these annual adjustments necessary. We
also adjusted analyses for income and population density.
Based on the number of comparisons made in the present
study, we focused on statistical significance for all analyses with
a 2-sided P value <.001.
For alcohol use, marijuana use, and their co-use, weighted
cross-tabulations estimated the prevalence of abstinence, non-
disordered use, and use disorders (separately for alcohol and
marijuana). Prevalence estimates were computed separately
among those in college and those not in college, followed by
multinomial regression analyses to evaluate the association
of year with alcohol and marijuana use status. The margins
command was used to evaluate annual change in models sig-
nificantly associated with year, controlling for the variables
noted above.
A third set of analyses used logistic regression to evaluate
the association of alcohol and marijuana use status with any
past-year prescription drug use, prescription drug misuse, pre-
scription drug use disorders, illicit drug use (cocaine, heroin,
hallucinogens, methamphetamine, or inhalants), or illicit drug
use disorders. Analyses controlled for sex, race/ethnicity,
family income, and population density, with past-year absti-
nence from both alcohol and marijuana set as the reference
group for the co-use variable. These analyses used data from
the 2015-2018 NSDUH data sets only, as the prescription use/
misuse assessment was changed between 2014 and 2015,
making comparisons of prescription use and misuse between
2015-2018 and 2002-2014 data invalid.29
Results
Between 2002 and 2018, a total of 182 772 US young adults aged
18 to 22 years completed the NSDUH. The weighted sample,
as described in eTable 1 in the Supplement, was 51.1% male,
48.9% female, 58.3% White, 19.7% Hispanic/Latino, 14.2%
Black, 4.9% Asian, 1.9% multiracial, and 1.1% other. Relative
to White respondents aged 18 to 22 years, the prevalence of
respondents who identified as Black, Asian, multiracial, or
Hispanic/Latino increased over time. While White respon-
dent prevalence decreased by 0.70% annually (95% CI, 0.61%-
0.79%), the prevalence of Black (0.03%; 95% CI, −0.04% to
0.08%), Asian (0.14%; 95% CI, 0.10%-0.18%), multiracial
(0.11%; 95% CI, 0.09%-0.12%), and Hispanic/Latino respon-
dents (0.43%; 95% CI, 0.35%-0.51%) increased. The propor-
tion of those in college increased and decreased over the study
period; however, the proportion of those not in college de-
creased by 0.16% annually (95% CI, 0.07%-0.24%) and re-
spondents who selected the other racial category increased by
0.08% per year (95% CI, 0.04%-0.12%).
As reported in Table 1,30 marginal estimates indicated
that past-year alcohol abstinence increased for both college
(Reprinted) JAMA Pediatrics Published online October 12, 2020 E3
 E4
Table 1. Trends in Abstinence, Substance Use Behaviors, and Disorders by College Statusa

Weighted %
Annualized change,
Variable 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 % (95% CI)
Unweighted sample size, No. 10 151 10 514 10 691 10 626 10 179 10 368 10 884 10 844 10 945 10 987 10 466 10 106 7250 7845 7325 7322 7456 NA
Alcohol: college students
Abstinence 20.0 18.6 20.2 20.0 18.1 19.9 21.7 19.5 20.6 23.9 23.8 24.2 26.3 27.4 26.9 28.7 28.0 0.54 (0.44 to 0.64)
Nondisordered alcohol use 60.3 62.6 60.3 60.5 62.1 60.8 60.2 63.7 62.1 60.6 61.1 63.0 60.7 61.7 62.5 62.3 62.2 0.13 (0.03 to 0.22)
Alcohol use disorder 19.7 18.8 19.5 19.5 19.8 19.3 18.2 16.8 17.3 15.5 15.1 12.8 13.0 10.9 10.6 8.9 10.0 −0.66 (−0.74 to −0.60)
Research Original Investigation

Alcohol: non–college students

Abstinence 23.6 24.2 23.3 25.5 25.6 24.8 24.2 23.1 24.1 26.3 24.3 25.5 24.7 26.8 29.9 28.2 29.9 0.33 (0.24 to 0.43)
Nondisordered alcohol use 57.2 59.1 58.1 56.9 57.4 57.8 59.1 60.0 59.6 59.6 61.2 61.5 62.8 62.6 59.4 61.9 60.8 0.28 (0.18 to 0.37)
Alcohol use disorder 19.2 16.7 18.7 17.6 17.0 17.4 16.8 16.9 16.2 14.1 14.6 13.0 12.5 10.6 10.7 9.9 9.3 −0.61 (−0.69 to −0.55)
Marijuana: college students
Abstinence 67.1 68.1 68.1 69.2 68.7 69.0 68.2 65.4 67.0 66.4 65.8 65.5 65.7 65.6 65.2 64.2 63.2 −0.41 (−0.51 to −0.31)
Nondisordered marijuana use 26.9 25.7 24.9 24.9 25.5 25.3 25.7 28.3 27.1 28.1 27.8 29.1 29.5 28.8 29.8 30.3 30.8 0.46 (0.37 to 0.55)
Marijuana use disorder 6.0 6.3 7.0 5.9 5.7 5.7 6.1 6.3 5.9 5.5 6.4 5.4 4.8 5.6 5.1 5.5 6.1 −0.05 (−0.10 to 0.01)
Marijuana: non–college students

JAMA Pediatrics Published online October 12, 2020 (Reprinted)

Abstinence 66.8 67.5 68.0 68.9 69.8 69.5 70.0 65.3 67.6 66.6 65.5 65.5 63.7 64.4 63.4 62.5 62.9 −0.41 (−0.51 to −0.31)
Nondisordered marijuana use 25.7 24.7 23.9 23.9 23.1 23.0 22.7 27.9 25.5 25.7 27.8 28.3 30.2 29.5 30.2 31.4 30.0 0.49 (0.40 to 0.59)
Marijuana use disorder 7.5 7.7 8.1 7.2 7.2 7.5 7.3 6.8 6.9 7.7 6.7 6.2 6.1 6.1 6.3 6.2 7.1 −0.09 (−0.14 to −0.04)
Marijuana and alcohol: college students
Abstinence of both 19.5 18.1 19.4 19.3 17.8 19.2 20.9 19.0 19.7 23.0 22.9 23.0 24.8 25.5 26.0 27.0 26.0 0.45 (0.35 to 0.55)
Nondisordered

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Alcohol use 40.4 42.9 41.6 42.4 43.2 42.4 40.2 40.7 40.6 38.0 38.0 38.5 36.8 37.1 35.7 34.6 34.3 −0.52 (−0.61 to −0.44)
Marijuana use 0.5 0.4 0.6 0.6 0.2 0.6 0.8 0.5 0.7 0.8 0.8 1.0 1.3 1.8 0.8 1.5 1.8 0.08 (0.05 to 0.10)
Co-use 17.1 16.9 16.1 15.6 16.3 16.0 17.0 19.9 18.5 19.9 19.8 21.3 21.2 21.4 23.6 24.3 24.0 0.60 (0.51 to 0.68)
Alcohol use disorder 16.6 15.4 15.3 16.2 16.7 16.1 15.1 13.7 14.6 12.8 12.0 10.7 11.0 8.7 8.9 7.2 7.9 −0.55 (−0.62 to −0.48)
Marijuana use disorder 2.9 2.9 2.8 2.5 2.7 2.5 3.0 3.2 3.2 2.8 3.4 3.4 2.8 3.3 3.4 3.7 4.1 0.06 (0.03 to 0.10)
Disordered co-use 3.1 3.3 4.2 3.4 3.1 3.2 3.1 3.1 2.7 2.7 3.0 2.0 2.1 2.3 1.7 1.8 2.0 −0.11 (−0.14 to −0.09)

© 2020 American Medical Association. All rights reserved.

Marijuana and alcohol: non–college students
Abstinence of both 22.3 22.7 22.4 24.0 24.1 23.8 23.0 21.6 22.8 24.1 22.6 23.8 22.6 24.6 27.1 25.7 26.8 0.22 (0.14 to 0.31)
Nondisordered
Alcohol use 37.0 38.3 38.5 38.2 38.5 39.3 40.5 37.8 38.6 37.3 37.2 37.6 36.4 36.8 33.0 34.2 33.4 −0.31 (−0.41 to −0.22)
Marijuana use 1.2 1.1 0.8 1.1 1.1 0.7 1.0 1.2 1.0 1.7 1.3 1.4 1.7 1.9 2.3 2.1 2.7 0.10 (0.07 to 0.13)
Co-use 17.0 17.3 15.8 15.4 15.8 15.4 15.1 19.1 17.8 18.4 20.2 20.7 22.7 22.5 22.7 23.8 23.0 0.56 (0.48 to 0.63)
Alcohol use disorder 15.0 12.9 14.4 14.1 13.4 15.1 13.2 13.6 12.9 10.9 12.0 10.2 10.5 8.1 8.7 8.1 6.9 −0.47 (−0.53 to −0.41)
Marijuana use disorder 3.3 4.0 3.9 3.7 3.5 3.8 3.8 3.5 3.6 4.5 4.1 3.5 4.1 3.6 4.4 4.4 4.7 0.05 (0.01 to 0.09)
Disordered co-use 4.2 3.8 4.2 3.5 3.7 4.1 3.6 3.3 3.3 3.2 2.6 2.8 2.1 2.5 1.9 1.8 2.4 −0.14 (−0.18 to −0.11)

Abbreviation: NA, not applicable.

a
Data from the US Department of Health and Human Services.30

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Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults
 Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults
Figure 1. Prevalence of Alcohol and Marijuana Use Groups
in US College Students: 2002-2018
ND alcohol use
ND marijuana use
ND co-use
50 Abstinence of both
Past-year prevalence of use, %
40
30
20
10
0 0
2002 2004 2006 2008 2010
Year
ND indicates nondisordered.
students and non–college students from 2002 to 2018. For ex-
ample, 20% of college students reported alcohol abstinence
in 2002, compared with 28% in 2018. Similarly, 23.6% of non–
college students reported alcohol abstinence in 2002 com-
pared with 29.9% in 2018. Alcohol use disorder prevalence de-
creased for both groups, with an annual decrease of 0.66%
(95% CI, 0.60%-0.74%) for college students and 0.61% (95%
CI, 0.54%-0.69%) for non–college students.
The past-year abstinence from marijuana use decreased
for both college students (0.41%; 95% CI, 0.31%-0.51%) and
non–college students (0.41%; 95% CI, 0.31%-0.51%) from 2002
to 2018. The past-year prevalence of nondisordered mari-
juana use increased for both college students (0.46%; 95% CI,
0.37%-0.55%) and non–college students (0.49%; 95% CI,
0.40%-0.59%) from 2002 to 2018. Past-year marijuana use dis-
order held relatively steady for college students and non–
college students from 2002 to 2018.
As shown in Figure 1 and Figure 2, college students and
non–college students both experienced increases in absti-
nence of marijuana and alcohol. Past-year nondisordered
co-use of alcohol and marijuana increased annually by simi-
lar amounts in college students (0.60%; 95% CI, 0.51%-
0.68%) and non–college students (0.56%; 95% CI, 0.48%-
0.63%).
Per Table 2,30 all alcohol and/or marijuana use groups
had higher rates of controlled prescription drug use, pre-
scription drug misuse, prescription drug use disorder, illicit
drug use, and illicit drug use disorder than abstinent (ie,
alcohol and marijuana) respondents. For prescription drug
use disorder and illicit drug use disorder, the nondisordered
alcohol use and abstinent groups did not differ significantly.
Most of those with both alcohol use disorder and marijuana
use disorder reported past-year prescription drug misuse
and past-year illicit drug use. Among young adults with both
alcohol use disorder and marijuana use disorder, the preva-
lence of all 3 prescription drug outcomes and illicit drug use
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Original Investigation Research
Figure 2. Prevalence of Alcohol and Marijuana Use Groups
in US Non–College Students: 2002-2018
Alcohol use disorder ND alcohol use Alcohol use disorder
Marijuana use disorder ND marijuana use Marijuana use disorder
Disordered co-use ND co-use Disordered co-use
50 Abstinence of both
Past-year prevalence of use, %
40
30
20
10
2012 2014 2016 2018 2002 2004 2006 2008 2010 2012 2014 2016 2018
Year
ND indicates nondisordered.
was higher among college students, while the prevalence of
illicit drug use disorder was higher among non–college stu-
dents. As presented in eTable 2 in the Supplement, young
adults who reported co-use or met criteria for alcohol use
disorder and/or marijuana use disorder accounted for 82.9%
of young adults with prescription drug use disorders and
85.1% of young adults with illicit drug use disorders.
As reported in Table 3,30 the most consistent covariates
across all of the outcomes were prescription drug misuse
and illicit drug use. For instance, young adults who had
engaged in prescription drug misuse had more than 2 times
greater odds of marijuana use disorder than young adults
who had not engaged in prescription drug misuse (college:
2.28; 95% CI, 1.71-3.03; non-college: 2.04; 95% CI, 1.62-2.58).
Similarly, young adults who reported illicit drug use had
over 4 times greater odds of marijuana use disorder than
young adults who did not report illicit drug use (college:
5.09; 95% CI, 3.86-6.70; non-college: 4.41; 95% CI, 3.48-
5.60). Prescription drug use was associated with lower odds
of abstinence (college: 0.60; 95% CI, 0.52-0.70; non-college:
0.65; 95% CI, 0.56-0.75) and increased odds of nondisor-
dered co-use (college: 1.41; 95% CI, 1.22-1.63; non-college:
1.32; 95% CI, 1.14-1.52) and marijuana use disorder (college:
1.85; 95% CI, 1.42-2.41) among young adults, except mari-
juana use disorder for non–college students. In contrast, reli-
giosity was related to higher odds of abstinence (college:
1.08; 95% CI, 1.06-1.10; non-college: 1.04; 95% CI, 1.03-1.06)
and lower odds of nondisordered co-use (college: 0.92; 95%
CI, 0.90-0.93; non-college: 0.94; 95% CI, 0.92-0.95) and
marijuana use disorder (college: 0.97; 95% CI, 0.94-0.99)
among young adults, except marijuana use disorder for non–
college students. We found sex differences in marijuana use
disorder for both college students (1.94; 95% CI, 1.57-2.41)
and non–college students (2.20; 95% CI, 1.80-2.71), with
men in each group having approximately 2 times higher
odds of marijuana use disorder.
(Reprinted) JAMA Pediatrics Published online October 12, 2020 E5
 Research Original Investigation Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults

Table 2. Prescription and Illicit Drug Use by Abstinence, Nondisordered Use, and Disordered Use, 2015-2018a,b

Past-year, weighted %
Prescription drug Other illicit drug
Unweighted
Variable sample size, No. Any use Any misuse Use disorder Use Use disorder
Alcohol and marijuana: college students
Abstinence of both 3739 23.6 2.1 0.3 2.8 0.3
Nondisordered
Alcohol use 5388 33.4 6.0 0.2 7.2 0.3
Marijuana use 209 42.8 10.9 0.4 16.0 1.3
Co-use 3378 52.3 25.5 1.1 35.1 1.9
Alcohol use disorder 1231 63.9 38.3 4.4 47.7 6.7
Marijuana use disorder 497 72.9 47.7 4.6 63.7 6.0
Disordered co-use 268 82.1 66.1 19.4 80.9 23.2
Alcohol and marijuana: non–college students
Abstinence of both 3988 25.7 3.0 0.5 3.9 0.6
Nondisordered
Alcohol use 5269 36.2 6.3 0.6 8.0 0.9
Marijuana use 375 36.6 16.1 3.6 22.2 4.8
Co-use 3397 51.6 25.0 2.3 36.4 4.6
Alcohol use disorder 1233 62.9 38.0 6.3 47.6 10.6
Marijuana use disorder 652 60.1 39.0 7.5 53.9 13.1
Disordered co-use 324 76.1 58.7 19.2 75.8 30.6
Alcohol and marijuana: overall
Abstinence of both 7727 24.6 2.5 0.5 3.3 0.5
Nondisordered
Alcohol use 10 657 34.3 6.0 0.4 7.5 0.6
Marijuana use 584 37.8 12.6 2.1 17.4 3.1
Co-use 6775 51.8 25.1 1.8 35.4 3.3
Alcohol use disorder 2464 63.5 38.2 5.5 47.7 8.8
Marijuana use disorder 1149 66.4 43.2 5.7 58.2 9.4
Disordered co-use 592 78.2 62.2 19.3 77.7 27.9
a
All comparisons are within column, with abstinence as the reference group. refers to heroin, cocaine, hallucinogens, inhalants, and methamphetamine.
Prescription drug refers to prescription opioids, prescription stimulants, b
Data from the US Department of Health and Human Services.30
and/or prescription sedatives/tranquilizers/anxiolytics. Other illicit drug use

geting US college students33,35-37 substantially addressed drink-

Discussion
Past-year abstinence from alcohol was more prevalent among
non–college students in the early 2000s relative to college stu-
dents; however, this gap has closed in recent years. More than
1 in every 4 (28%) college students in the US were abstinent
from alcohol use, or approximately 3 000 000 US college stu-
dents in 2018. We found that increases in alcohol abstinence
were accompanied by decreases in alcohol use disorder among
college and non–college students. These changes may be in-
fluenced by increases in the number of US young adults liv-
ing with their parents,10,31,32 which could promote increased
alcohol abstinence and decreased alcohol use disorder as found
in the present study. These changes may also be an example
of the prevention paradox, where upstream interventions
aimed at low- to moderate-risk drinking populations more sub-
stantially address overall drinking-related problems in young
adults than interventions solely for high-risk groups.33,34 Per-
haps increased alcohol prevention and intervention efforts tar-
ing-related problems among this low- to moderate-risk group.
There was an increase in nondisordered marijuana use
from 2002 to 2018 without an increase in marijuana use
disorder among US young adults. This finding is consistent with
earlier changes reported in the US population, indicating an
increase of 19% in the annual past-year prevalence of mari-
juana use between 2002 and 2013 without an increase in
marijuana use disorder.38 Nevertheless, the trends in mari-
juana use and marijuana use disorder remain important to
monitor both cross-sectionally and prospectively given that
marijuana use among US young adults has reached its high-
est level in several decades.39
Nondisordered co-use of alcohol and marijuana in-
creased between 2002 and 2018 among US young adults. For
example, approximately 2.6 million college students co-used
alcohol and marijuana in 2018, as opposed to approximately
1.8 million college students in 2002. Those engaging in simul-
taneous use of alcohol and marijuana (ie, use of both sub-
stances on the same occasion) tend to use both substances

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 Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults Original Investigation Research

Table 3. Multivariable Results: Past-Year Abstinence, Co-Use, and Marijuana Use Disorder, 2015-2018a,b

AOR (95% CI)

Alcohol and marijuana abstinence Alcohol and marijuana co-use Marijuana use disorder
College Non–college College Non–college College Non–college
Variable students students students students students students
Unweighted sample size, No. 12 762 14 268 12 762 14 268 12 762 14 268
Sociodemographic covariates
Male 1.21 (1.11-1.33) 1.07 (0.95-1.21) 0.96 (0.87-1.06) 1.01 (0.88-1.15) 1.94 (1.57-2.41) 2.20 (1.80-2.71)
White 0.60 (0.54-0.67) 0.71 (0.63-0.80) 1.14 (0.99-1.30) 0.98 (0.87-1.10) 0.80 (0.62-1.03) 0.59 (0.48-0.72)
Poverty 0.79 (0.68-0.91) 1.55 (1.37-1.76) 1.22 (1.09-1.37) 0.97 (0.84-1.11) 1.06 (0.82-1.36) 0.98 (0.79-1.22)
CBSA >1 million 1.12 (0.99-1.25) 0.86 (0.77-0.97) 1.08 (0.98-1.20) 1.13 (1.04-1.24) 0.96 (0.77-1.18) 1.13 (0.91-1.39)
Religiosity 1.08 (1.06-1.10) 1.04 (1.03-1.06) 0.92 (0.90-0.93) 0.94 (0.92-0.95) 0.97 (0.94-0.99) 0.99 (0.96-1.02)
Lesbian/gay 1.21 (0.76-1.91) 0.58 (0.38-0.90) 1.42 (1.03-1.97) 1.41 (1.03-1.93) 0.87 (0.53-1.43) 0.82 (0.49-1.36)
Bisexual 1.03 (0.79-1.36) 0.82 (0.68-1.00) 1.17 (0.98-1.40) 1.44 (1.19-1.75) 1.02 (0.67-1.55) 1.17 (0.86-1.61)
Physical health covariates
Self-reported fair or 1.21 (0.90-1.64) 1.18 (0.94-1.49) 0.93 (0.68-1.25) 0.99 (0.82-1.20) 1.24 (0.73-2.12) 1.20 (0.94-1.53)
poor health
Overweight/obese BMI 0.93 (0.82-1.05) 1.07 (0.98-1.18) 0.93 (0.83-1.05) 0.88 (0.78-0.98) 1.03 (0.82-1.30) 0.78 (0.64-0.96)
Past-year hospitalization 1.44 (1.11-1.88) 1.58 (1.34-1.85) 0.87 (0.65-1.16) 0.69 (0.54-0.87) 1.01 (0.68-1.61) 1.01 (0.71-1.44)
Mental health covariates,
past year
Mental health treatment 1.19 (1.02-1.40) 1.10 (0.96-1.26) 0.98 (0.80-1.18) 0.97 (0.82-1.15) 1.33 (1.01-1.76) 1.13 (0.86-1.50)
Major depression 1.27 (1.01-1.61) 1.28 (1.03-1.60) 0.92 (0.75-1.14) 1.12 (0.89-1.40) 0.95 (0.70-1.29) 1.15 (0.83-1.60)
Psychological distress 0.79 (0.67-0.93) 1.06 (0.87-1.28) 0.98 (0.79-1.21) 0.81 (0.69-0.95) 1.46 (1.09-1.97) 1.50 (1.16-1.93)
WHO disability scale 1.02 (1.01-1.03) 0.99 (0.98-1.00) 0.98 (0.97-0.99) 1.00 (0.99-1.01) 1.05 (1.02-1.07) 1.04 (1.02-1.06)
Suicidal ideation 0.93 (0.76-1.12) 0.85 (0.68-1.07) 0.92 (0.75-1.12) 1.09 (0.86-1.38) 1.14 (0.86-1.51) 1.41 (1.07-1.86)
Substance use covariates,
past year
Prescription drug use 0.60 (0.52-0.70) 0.65 (0.56-0.75) 1.41 (1.22-1.63) 1.32 (1.14-1.52) 1.85 (1.42-2.41) 1.14 (0.91-1.43)
Prescription drug misuse 0.21 (0.15-0.31) 0.34 (0.25-0.47) 1.53 (1.27-1.83) 1.40 (1.18-1.65) 2.28 (1.71-3.03) 2.04 (1.62-2.58)
Other illicit drug use 0.08 (0.04-0.15) 0.11 (0.08-0.17) 1.86 (1.60-2.17) 2.14 (1.88-2.44) 5.09 (3.86-6.70) 4.41 (3.48-5.60)
Abbreviations: AOR, adjusted odds ratio; BMI, body mass index (calculated as and/or prescription sedatives/tranquilizers/anxiolytics. Other illicit drug use
weight in kilograms divided by height in meters squared); CBSA, US Census refers to heroin, cocaine, hallucinogens, inhalants, and methamphetamine.
core-based statistical area; WHO, World Health Organization. b
Data from the US Department of Health and Human Services.30
a
Prescription drug refers to prescription opioids, prescription stimulants,

more frequently, use greater quantities, and experience more
substance-related consequences.40 Although alcohol use
disorder is declining and alcohol abstinence is increasing in
parallel, the legal landscape of marijuana is changing and the
percentage of tetrahydrocannabinol in marijuana strains
has steadily increased in recent decades,41 with evidence of
an increase in risk related to development of symptomatic
marijuana use, 42 marijuana use disorder severity, 43 and
psychosis.44,45 Therefore, clinicians and physicians have a com-
plex task in developing effective programs to reduce the risk
of negative consequences associated with the rising preva-
lence of marijuana use and co-use of alcohol and marijuana.
In addition, schools and employers may require additional re-
sources to scale interventions to address both individuals with
and without a disorder, including brief interventions for non-
disordered co-use of alcohol and marijuana.
More than three-fourths of young adults who met criteria
for both alcohol use disorder and marijuana use disorder re-
ported past-year prescription drug use (78.2%) and illicit drug
use (77.7%); 62.2% reported prescription drug misuse. Pre-
scription drug misuse is more prevalent among young adults
than any other age group in the US.39,46,47 Young adults who
reported co-use of alcohol and marijuana or met criteria for al-
cohol use disorder and/or marijuana use disorder accounted
for 82.9% of young adults with prescription drug use disor-
der and 85.1% of those with illicit drug use disorder. Current
national studies and diagnostic instruments often focus on in-
dividual drug classes and can miss changes in co-use as sug-
gested by the present study. This assessment gap impacts pre-
vention and intervention efforts because an individual may not
be considered at risk based on any single substance; how-
ever, the same individual could be at risk for dangerous drug
interactions (eg, combining central nervous system depres-
sants). Therefore, clinicians are encouraged to screen for a wide
range of substances and polysubstance use to detect risky use
behaviors. Similarly, the high prevalence of prescription drug
use among young adults who report co-use of alcohol and mari-
juana or met criteria for alcohol use disorder and/or marijuana
use disorder reinforces the importance of carefully monitor-
ing use of controlled substances among such individuals.

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 Research Original Investigation Changes in Alcohol and Marijuana Abstinence, Co-Use, and Use Disorders Among US Young Adults

Limitations in DSM-5-classified alcohol use disorder and marijuana use

The results of the present study should be considered within
the context of its limitations. First, the cross-sectional design
of the NSDUH precludes any causal determinations regarding
the temporal associations between substance use and educa-
tional status. Second, all measures were self-reported and, al-
though all measures are considered reliable and valid, stud-
ies suggest that misclassification and underreporting of
sensitive behaviors such as substance use can occur.48,49 Also,
we combined illicit drugs and additional research is needed that
considers individual drugs to help detect emerging drug pat-
terns (eg, methamphetamine and heroin), including co-use.
While we adjusted for relevant sociodemographic character-
istics associated with college enrollment and substance use,
the secondary analyses were limited to the available vari-
ables, and other factors that may influence the associations
could not be included (eg, social context and substance avail-
ability). In addition, the present study was constrained by the
NSDUH measures, such as the DSM-IV criteria used to deter-
mine SUD, and further work is needed to examine the trends
disorder among US young adults.
Conclusions
The findings of this study suggest that greater attention is
needed to provide a diverse set of social support services and
resources to the growing number of US young adults in col-
lege and not in college who are abstinent from alcohol, includ-
ing those in recovery and those abstinent for other reasons.
In addition, screening for co-use of alcohol and marijuana, al-
cohol use disorder, and marijuana use disorder provide op-
portunities for clinicians to detect illicit drug use, prescrip-
tion drug misuse, and other SUDs. Colleges and communities
in the US must find ways to address the changing landscape
of substance use behaviors by providing support to the in-
creasing number of young adults who are abstinent, while also
creating interventions to address the increases in marijuana
use and co-use of alcohol and marijuana.

ARTICLE INFORMATION
Accepted for Publication: June 17, 2020.
Published Online: October 12, 2020.
doi:10.1001/jamapediatrics.2020.3352
Author Affiliations: Center for the Study of Drugs,
Alcohol, Smoking and Health, University of
Michigan School of Nursing, Ann Arbor (McCabe,
Arterberry, Dickinson, Evans-Polce, Ryan); Institute
for Research on Women and Gender, University of
Michigan, Ann Arbor (McCabe); Survey Research
Center, Institute for Social Research, University of
Michigan, Ann Arbor (McCabe); Center for Sexuality
and Health Disparities, University of Michigan
School of Nursing, Ann Arbor (McCabe); Institute
for Healthcare Policy and Innovation, University of
Michigan, Ann Arbor (McCabe); Department of
Psychology, Iowa State University, Ames
(Arterberry); Department of Sociology, University
of Central Florida, Orlando (Ford); Department of
Psychology, Texas State University, San Marcos
(Schepis).
Author Contributions: Drs McCabe and Schepis
had full access to all of the data in the study and
take responsibility for the integrity of the data and
the accuracy of the data analysis.
Concept and design: McCabe, Arterberry, Dickinson,
Ford, Ryan, Schepis.
Acquisition, analysis, or interpretation of data:
McCabe, Evans-Polce, Ford, Schepis.
Drafting of the manuscript: McCabe, Dickinson.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: McCabe, Schepis.
Obtained funding: McCabe, Schepis.
Administrative, technical, or material support:
McCabe, Ryan.
Supervision: McCabe.
Conflict of Interest Disclosures: Dr Arterberry is
vice president of the Source Research Foundation,
a nonprofit research and educational organization
that supports students who study the
epidemiology, phenomenology, and the
environmental, cultural, and clinical contexts of
psychedelic use. Dr Arterberry is also a paid
consultant for Innovation Research and Training,
a company dedicated to applying scientific findings
to real-world problems.
Funding/Support: This research was supported by
research grants R01DA031160, R01DA036541, and
R01DA043691 from the National Institute on Drug
Abuse, National Institutes of Health, and grant
NR016914 from the National Institute of Nursing
Research.
Role of the Funder/Sponsor: The National
Institute on Drug Abuse, National Institutes of
Health had no role in the design and conduct of the
study; collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Additional Contributions: Kate Leary, BS
(Center for the Study of Drugs, Alcohol, Smoking
and Health research administrator), provided
editorial and formatting assistance with the
manuscript; no financial compensation was
provided. We thank the anonymous reviewers and
editorial team for their detailed review and helpful
suggestions to earlier versions of the manuscript.
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