Youth Perspectives about the Impact of COVID-19 on Substance Use

In response to the unprecedented health threat of the COVID-19 pandemic, governments across the world enacted quarantine restrictions including stay-at-home orders, social distancing, and closure of schools and universities in March 2020. In the United States, over 70 million young people were affected by school and university closures and restrictions that continued into 2021 [1]. Although young people are at lower risk of severe disease and death from COVID-19, they may be disproportionately impacted by the social isolation and stress that have resulted from these mitigation strategies [2]. Adolescence and young adulthood are times of rapid social and emotional development, with adolescence being a period of substance use initiation and experimentation [3] and young adulthood a period characterized by substance use normalization, peak use, and the development of substance use disorders [4]. Concerns have been raised among the public health and medical communities that the abrupt transition to remote education, prolonged social isolation, and disruption of developmental milestones that young people experienced during the COVID-19 pandemic may contribute to increased substance use among youth [5,6]. While our understanding of the impact of COVID-19 on young people is still limited, studies suggest that the pandemic has had a strong impact on both mental health and substance use among youth [7]. 

Recent studies have found conflicting trends in the directionality of pandemic related youth substance use, with some reporting decreases in use of specific substances and others reporting increases [8-10]. The impact of the pandemic on adolescent substance use, in particular, is unclear. One longitudinal analysis of a national cohort of 7,800 youth ages 10-14 found that during the pandemic, the overall rate of substance use did not change but the type of substances used did, with alcohol consumption decreasing while use of nicotine and prescription medication increased among young adolescents [11]. The nationally representative Monitoring the Future survey found that among older adolescents, nicotine and vaping declined, but alcohol consumption, including binge drinking, and cannabis use remained stable despite youth perceptions that substances were less available [12]. In contrast, young adults more consistently report increased substance use during the pandemic. In national surveys conducted in the U.S. between April-June 2020, young adults 18-24 years of age were the most likely age group to report initiation or increase of substance use to cope with pandemic-related stress. Another survey of young adults in the U.S. conducted in May 2020 found that young people ages 18-35 reported increases in loneliness and alcohol use in these first several months of the COVID pandemic [7]. Experiences of loneliness and pandemic-related stress have been found to be significantly related to drinking to cope with stress among college students in the U.S., and stress-based drinking is subsequently related to cannabis consumption [13]. 

The effects of the COVID-19 pandemic on substance use in adolescents and young adults is likely complex and may vary across different developmental periods and types of substances, leading to simultaneous increases and decreases as a result of a multitude of ecological factors. In addition to loneliness and pandemic-related stress several contextual factors, including access to substances, history of previous substance use, and location of residence seem to impact changes in use; however, more research is needed to understand the role these factors play in how the pandemic is impacting substance use among young people. In this study, we sought to explore the factors and motivations that may have both increased and decreased substance use during the COVID-19 pandemic based on the experiences and perspectives of young people themselves. Using qualitative data provides an opportunity to reflect upon the nuanced and sometimes conflicting trends seen in observational studies during this time. Understanding the reasons and underlying mechanisms of youth substance use during the COVID-19 pandemic and the nuances of how the pandemic has impacted substance use among young people is vital to supporting young people’s health and developing prevention and intervention strategies to mitigate the long-term impacts of the pandemic.

Our study utilized the MyVoice cohort, a longitudinal national text message survey of youth ages 14-24. Participants in MyVoice were recruited and enrolled via targeted social media advertisements focused on demographic benchmarks based on weighted samples of the American Community Survey for age, gender, race and ethnicity, socioeconomic status, and region of the country (additional MyVoice study details can be found in [14]). Demographic data were collected from participants at enrollment, and enrolled participants were sent weekly surveys with 3-5 questions on health and policy topics impacting youth. Participants earned $1 per week for responding to these survey questions and could text “stop” at any time to be removed from the study. This study was approved by the University of Michigan Institutional Review Board with a waiver of parental consent for minor participants to enable equitable enrollment. 

On May 15, 2020, MyVoice participants were sent four open-ended questions via text message regarding their perceptions of substance use during the COVID-19 pandemic. Iteratively developed questions by a team of youth, methodology experts, and adolescent health researchers resulted in the following language: 

• This week is about substance use (juul/vaping, alcohol, marijuana, etc.,) during the COVID-19 pandemic. Do you think substance use among people your age has changed during the pandemic (same/less/more)?
• What do you think are some reasons substance use has changed for you or people your age due to the pandemic, if at all?
• How do you think access to substances has changed for you or people your age due to the pandemic, if at all?
• Do you think the pandemic has affected the use of one type of substance more than others? If yes, how? 

One week after the questions were released, all responses were downloaded and prepared for analysis. A codebook was iteratively developed by the study team using an inductive approach. Three team members (NH, KH and BB) independently reviewed and created memos describing the content of 100-200 responses to each question, which were then discussed and agreed upon to iteratively develop a final set of codes. The codebook was then independently applied to all text responses by three reviewers (NH, KH and BB) with discrepancies between coders resolved through discussion until agreement was reached. Descriptive statistics were then calculated using Excel 2016 for code frequencies and demographic data from participants.

Out of the 1,160 active MyVoice participants, 972 responded to the survey (83.8% response rate) comprised of 368 adolescents ages 14-17 (37.9%) and 604 young adults ages 18-24 (62.1%). Participant demographic characteristics are summarized in table 1. 

Table 1: Respondent demographic characteristics.

*includes respondents still in high school 

Table 2 shows the most frequently identified thematic codes by question and illustrative quotes representing each code for adolescents and young adults. In question 1, 43.5% of adolescents and over half of young adult respondents (56.6%) reported that substance use among people their age had increased during the pandemic, while 22.6% of adolescents and 13.8% of young adults felt that substance use was “less likely to happen”. Question 2 asked respondents to share reasons why substance use has changed among people their age. Boredom during stay at home orders (reported by 41.7% and 51.6%), followed by coping with the mental health toll of the pandemic (reported by 31.5% and 41.0%), and social/ physical restrictions (26.1% and 23.1%) were the top drivers of change in substance use identified by both adolescents and young adults respectively. For adolescents, almost one out four respondents (23.1%) reported that access to substances had an impact on substance use among people their age, whereas only 12.0% of young adults named access as a reason for change. Other reasons youth gave for changes in substance use included financial challenges, such as “having less money from losing jobs” which was reported more frequently by young adults (5.9%) than adolescents (3%). Concerns about health and contracting COVID were reported similarly across the two age groups: 3.6% for adolescents and 3.0% for young adults. 

Table 2: Questions, themes and example participant quotes. 

Responses indicated that some factors contributed to both more and less substance use including social and physical restrictions; “stuck at home and restricted from going out”, access to substances and suppliers; “Either more or less connection to those who supply them”, and the person’s living environment; “People my age have less privacy if they live with their families, so it’s difficult to use these substances without getting caught”, and “People with relaxed parents who let them drink with them in the house”. Other themes such as financial challenges; “Maybe they have been laid off of jobs that previously allowed them to afford such substances” and COVID-19 related health concerns; “Because they want to stop the lung damage in case they get the virus” were associated with decreased use, while boredom; “People are stressed and bored, looking to escape” and coping with mental health issues related to COVID-19; “It's a pretty bleak situation and sometimes people feel like it’s a good way to temporarily escape from reality” were associated with increases in use. 

When asked how access to substances has changed during the pandemic (Question 3), the majority of adolescents (62.6%) but a little less than half of young adults (47.1%) believed that access to substances had decreased due to the pandemic. Some youth also reported that while demand for substances had increased during the pandemic, supply had decreased. Factors like financial access and living environment were seen by some as facilitating decreased access (“I think access might have dwindled due to social distancing and lessened incomes”; “Most access has gotten harder since you’re with your family the whole time”), while others considered these as reasons for increased access (“More money, more time, more options”; “The birth of delivery apps means we can get alcohol or nicotine delivered no problem these days”). More young adults believed access to substances had not changed during the pandemic (21.1%) compared to adolescents (1.2%). Alternative ways of accessing substances and young people’s disregard for social distancing mandates were the main reasons respondents felt that access to substances had not changed; “I think access has more or less stayed the same due to the large amount of delivery services (e.g. marijuana deliveries to your front door”). Adolescents and young adults reported increased access to substances similarly (6.7% adolescents vs. 6.9% young adults). Despite developmental differences in changes to perceived and personal access to substances, the leading reason for changes to access identified by both adolescents and young adults was social and physical restrictions imposed during the pandemic (28.4% and 20.5%). 

We also asked young people whether the pandemic had impacted the use of one type of substance more than others (Question 4). Of the 327 respondents who provided examples of increased substance use, both adolescents and young adults participants felt that the use of alcohol was the most affected (reported by 40.0% adolescents and 61.7% young adults; “Definitely alcohol, cultural coping mechanism”) and nearly one third (29.5% adolescents and 32.9% young adults) suggested marijuana use increased (“There isn't pressure to get up early so I can smoke on nights I normally would not have”). The responses of the 103 young people who reported decreases in specific substance use were more divided. Young adults who perceived less use during the pandemic more frequently identified reduced alcohol consumption (24.1%); “Alcohol use since it is so often consumed in social settings,” while the most commonly mentioned substances for adolescents were reduced marijuana and hard drug usage (26.7%); “things like meth or LSD aren’t really possible to buy in a store or grow yourself”. Most responses focused on changes in access to substances and how access has impacted changes in use. Some responses were excluded from table 2 due to insufficient detail. These included respondents who indicated “smoking” without specifying substance type (reported by 11%) and those who indicated “legal drugs” without providing sufficient detail to categorize their response (reported by 8%).

The results of this study show that changes in youth substance use and views of access during the pandemic varied depending on the type of substance and developmental age, as well as contextual factors such as location of residence. Substance use increased for some young people due to boredom during stay at home orders and as a way to cope with the mental health impact of the pandemic, while for others substance use decreased because of financial challenges and concerns about contracting COVID. Access to substances stood out as a key driver of both increases and decreases in use, depending on the type of substance and the person’s specific context, primarily for adolescent users. While the proliferation of delivery services and apps meant that alcohol, marijuana, and some nicotine products were easier to access, the availability of other substances like hard drugs and vaping products reportedly decreased. Despite decreased access, adolescent and young adult respondents in our study still reported increases in substance use among people their age, indicating that some young people went out of their way to use substances during the pandemic. 

Our results align with several recent studies of youth substance use have also found that access to substances and the type of substances used by young people influenced how use changed during the pandemic [8-10]. Gaiha and colleagues found that young people who were previous users or who reported nicotine dependence increased their use during the pandemic, indicating that changes in use may differ for those who have a history of substance use and that the pandemic may have exacerbated existing substance use behavior [10]. While our study did not specifically explore how previous use impacted current use during the pandemic, more research is needed in this area to understand the pandemic’s impact on youth with a history of substance use or dependence. 

Some factors, such as social and physical restrictions, were also seen as driving both increases and decreases in substance use for both adolescents and young adults. For some, social isolation and physical restrictions resulted in increased stress and increased substance use as a way to cope, while for others the decrease in social engagements and less access to social environments where substances are typically used by young people, such as parties, resulted in decreased use. Similarly, the parameters of the youth’s living environment was reported to contribute to both increases and decreases in substance use, especially for alcohol. While some young people experienced increased parental supervision and decreased access, others had more access to substances while at home. White and colleagues found a similar trend in their study of alcohol consumption among college students. Young people who moved back in with their parents during the pandemic reported significantly less drinking post-COVID than those who remained with their peers [9]. Similarly, a study of Canadian youth found significant decreases in binge drinking during the pandemic, but no change in the proportion of alcohol users and an increase in frequency of alcohol use among users [8]. 

Both adolescents and young adults who felt that the pandemic impacted one type of substance more than others reported that alcohol use had increased. Some of these increases were driven by changing family dynamics, like parents providing alcohol at home, while others used alcohol as a coping mechanism for pandemic related stress. Changes in alcohol use and use settings, such as using at home or with parents, can have long term consequences for young people. Although parents may feel that allowing their adolescent to drink can be a method of harm reduction or education around alcohol, this practice has not been shown to decrease adolescent and young adult drinking and in fact is associated with a higher odds of binge drinking, more frequent drinking, faster progression to heavy drinking, and alcohol-related harm [15-17]. Studies from Europe and Australia have also found that parents’ drinking and attitudes around drinking influence their children’s substance use [18-20]. In addition to changes in family relationships with substances, the increase in drinking to cope while in isolation may be a warning sign of the changing context of youth substance use. While typically adolescents use substances in social settings or with friends [21], the pandemic may be leading to more solitary use and using as a coping mechanism. Using substances alone is associated with coping motives in adolescents and can be a risk factor for later substance use disorder symptoms [22,23]; therefore, this may be an especially important area for intervention and prevention efforts with young people. 

Our study has several limitations. While a text-message survey format allowed us to reach a large sample of young people and collect open-ended responses, it did not allow us to capture the full stories and context of participants because we could not follow-up or clarify responses. For example, in some responses young people provided little detail, such as just writing “smoking”, which limited our ability to interpret the data. Respondents’ different levels of experience with some substances may also influence their knowledge and opinions regarding substance use, which may bias their responses. To minimize confidentiality concerns, we did not ask participants about their personal substance use; therefore, we were unable to assess differences in opinions between users and non-users in this sample. Although the MyVoice cohort is a large cohort of youth from the United States, it is not nationally representative therefore limiting the generalizability of our findings.

Despite these limitations, our findings have several important implications for providers who work with young people. This study supports the concerns in the medical and public health communities about the pandemic’s impact on substance use and provides important context about the multiple factors that may impact how young people’s substance use changed during the pandemic. Respondents in our study described different changes in substance use that depended on a person’s context, therefore it may not be possible to predict the pandemic’s impact on a young person’s substance use without understanding their unique situation. As the impacts of the pandemic become more apparent, it will be important for providers to screen all young people for substance use and to take into account their unique context and reasons for use when providing counseling and support.

The authors would like to thank Marika Waselewski for her contribution to this work.

All authors declare no conflict of interest.

This work was supported by the Michigan Institute for Clinical & Health Research, the University of Michigan MCubed program, the University of Michigan, Department of Family Medicine and the Conrad N. Hilton Foundation (Grant 17260). These funders 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.

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