Association Between Substance Use Experience and the Risk of Suicidal Behaviors Among Adolescents Based on Parental Cohabitation,Korea,2023

Abstract

Objective:

Adolescent substance use is an important public health concern associated with suicidal behaviors. Although parental cohabitation is considered protective, limited is known about its role in the relationship between substance use and suicidality. This study examined differences in suicidal behaviors according to substance use experience and parental cohabitation among Korean adolescents.

Methods:

We analyzed data from the 2023 Korea Youth Risk Behavior Web-based Survey (N = 52 880). Participants were categorized by lifetime substance use (ever user vs nonuser) and parental cohabitation (living with parents vs not living with parents). Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% CIs for suicidal ideation, planning, and attempts, controlling for sociodemographic and behavioral factors.

Results:

Compared with nonusers living with parents, nonusers not living with parents showed increased odds of suicidal ideation, planning, and attempts (AOR = 1.40, 1.92, and 2.91, respectively). Ever users living with parents also had elevated odds (AOR = 2.67, 6.44, and 11.04, respectively). The highest risks were observed among ever users not living with parents (AOR = 3.46, 8.86, and 37.92, respectively). The prevalence of suicide attempts ranged from 3.0% among nonusers living with parents to 61.9% among ever users not living with parents.

Conclusion:

Substance use and absence of parental cohabitation were independently and jointly associated with increased odds of suicidal behaviors. Adolescents with both risk factors exhibited the greatest vulnerability, highlighting the importance of family support and substance use prevention in suicide prevention efforts.

Keywords

adolescent substance use parents suicidal ideation suicide attempted

Introduction

Adolescent substance use is a serious public health concern that affects not only physical health but also mental well-being. The Centers for Disease Control and Prevention reported that 41.5% of US high school students had consumed alcohol and 22.9% had used marijuana in 2021.¹ In South Korea, the Supreme Prosecutors’ Office reported that drug-related crimes among people aged <19 years increased from 143 cases in 2018 to 1477 cases in 2023, representing a 10.3-fold increase in relative terms and indicating a notable upward trend in adolescent drug-related offenses.² Digital platforms such as social media, messenger applications (apps), and the dark web provide anonymity and convenience, creating accessible channels through which adolescents can obtain drugs.³

Adolescent suicide is regarded as one of the most serious public health issues in South Korea. The 2023 Causes of Death Statistics indicated that the suicide rate among adolescents was 7.9 per 100 000 people, making suicide the leading cause of death in this age group. Korean National Police Agency data indicate that from 2020 to 2023, the number of suicide deaths among middle school students increased from 28 to 93, representing a 232% increase, while suicide deaths among high school students increased from 83 to 106, representing a 28% increase.⁴

Previous studies have reported associations between adolescent substance use and suicidal behaviors.^5-7 Adolescent substance use has been shown to alter major neurotransmitter systems, such as dopamine, serotonin, and glutamate, which may contribute to reduced impulse control, heightened emotional instability, and increased vulnerability to depressive symptoms and suicidal behaviors.^8,9 Substance use is also associated with psychosocial difficulties, including deterioration of peer relationships, increased family conflict, and difficulties in school adjustment, which may be associated with elevated suicidal risk.^5-7

Family environment plays a critical role in adolescent health. Parental involvement and emotional bonds are key protective factors against risky behaviors,¹⁰ and adolescents in single-parent households face greater substance use risk than adolescents in 2-parent households.¹⁰ Furthermore, living apart from parents or experiencing persistent family conflict is associated with increased likelihood of substance use, social isolation, and emotional instability among adolescents.¹¹ Not living with both biological parents is also a significant predictor of suicidal acts in adolescents,¹² and among Korean adolescents, those not living with both biological parents had significantly higher odds of suicidal ideation and planning than those living with both biological parents.¹³

Consistent with the stress-buffering hypothesis, parental cohabitation may reduce adolescents’ risk of suicidal behaviors by increasing opportunities for day-to-day contact and timely support, which could soften the effect of stress on adolescents’ mental health and allow parents to notice signs of distress earlier.^14,15 Based on routine activity theory, this protective effect is related to the limitation of unstructured time and unmonitored peer activity, which may otherwise increase adolescents’ exposure to deviant behaviors.¹⁶ Whether parental cohabitation modifies the association between substance use and suicidal behaviors and whether population-based evidence adequately characterizes differential risk across cohabitation status remains insufficiently understood. Therefore, the present study aimed to examine the moderating effect of living with parents on the association between adolescent substance use and suicidal behaviors.

Methods

Participants

This nationwide, cross-sectional study used data from the 2023 Korea Youth Risk Behavior Survey (KYRBS),¹⁷ a school-based, nationally representative survey conducted annually by the Korea Disease Control and Prevention Agency (KDCA) to monitor health-risk behaviors among Korean adolescents. The KYRBS has a multistage stratified cluster sampling design that selects a representative sample of middle and high school students across South Korea.

In the 2023 cycle, a total of 56 935 students from 799 schools were invited to participate, and 52 880 students completed the web-based questionnaire (response rate: 92.9%). The survey was anonymously self-administered on school computers during regular class hours. Students absent on the survey day, those with cognitive or physical impairments preventing independent completion, and out-of-school adolescents were excluded.

The KDCA performed quality management and cleaning of KYRBS data, excluding cases with missing or implausible values (Figure 1).

This study is a secondary analysis of deidentified, publicly available data from the KYRBS, an anonymous, self-administered online survey designated by Statistics Korea as a government-approved official statistics program (approval no. 117058). Because the analysis used anonymized public data, the Catholic University of Korea Institutional Review Board determined the study to be exempt from review (exemption no. MC25ZASI0064).

This study was conducted based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (eTable 1 in the Supplement).

Exposure

Substance use was defined as having ever used any substance at least once in one’s lifetime. Substance use was assessed using the question, “Have you ever intentionally or habitually used substances such as drugs, inhalants such as glue sniffing, marijuana, cocaine, or butane gas for inhalation?” Participants who responded yes were classified as ever users, and those who responded no were categorized as nonusers. We stratified participants by their current living arrangement, specifically whether they currently lived with their parents. The survey included a question to determine whether adolescents were currently living with their parents by asking them to select 1 of 5 options describing their current living arrangement: (1) living with parents, (2) living with relatives, (3) boarding or renting (including living with friends), (4) living in a dormitory, or (5) residing in a child welfare institution such as an orphanage or group home. For this study, those who selected option 1 were classified as “currently living with parents,” and those who selected any of options 2 through 5 were classified as “currently not living with parents.”

Outcomes

This study measured 3 suicide-related outcomes: suicidal ideation, suicide planning, and suicide attempt. Suicidal ideation was assessed using the question, “During the past 12 months, have you seriously thought about committing suicide?” (yes/no). Suicide planning was assessed using the question, “During the past 12 months, have you made a specific plan to commit suicide?” (yes/no). Suicide attempt was assessed using the question, “During the past 12 months, have you attempted suicide?” (yes/no).

We included covariates in the multivariate logistic regression models to adjust for potential confounding. These variables—sex, school level, region, socioeconomic status, academic achievement, lifetime smoking experience, and lifetime alcohol experience—were selected based on their availability in the KYRBS and their use as control variables in previous epidemiological studies on adolescent substance use and suicidality. All covariates were treated as categorical variables. Socioeconomic status and academic achievement were recategorized from 5 to 3 levels (high, middle, low)¹⁸; smoking and alcohol experience were coded as binary variables (yes/no).

Statistical Analysis

We calculated descriptive statistics using complex survey-weighted frequency analyses to examine the distribution of sociodemographic and behavioral characteristics by substance use status and parental co-residence. We conducted group comparisons using the Rao–Scott χ² test to account for the complex sampling design of the KYRBS.

To evaluate associations between substance use and suicide-related outcomes, we performed logistic regression analyses. We first used univariate models to calculate crude odds ratios (ORs) and 95% CIs. We subsequently conducted multivariate logistic regression models, incorporating sampling weights, stratification, and clustering variables provided by the KYRBS. These models estimated adjusted ORs (AORs), controlling for potential confounders including age, sex, socioeconomic status, smoking, and alcohol use.

To assess effect modification, we tested multiplicative interaction by including a product term (substance use × parental cohabitation) in the multivariate logistic regression model, and we quantified the additive interaction as the relative excess risk due to interaction (RERI).¹⁹ A RERI >0 indicates a positive additive interaction between the 2 factors (eTable 2 in the Supplement).

We also compared the prevalence of suicide-related outcomes across the 4 groups using the Rao–Scott χ² test, with P < .05 considered statistically significant. We performed all analyses using SAS version 9.4 (SAS Institute Inc) with procedures appropriate for complex survey data.

Results

Of 52 880 adolescents surveyed, 52 036 (98.4%) had no experience with substance use and 837 (1.6%) reported having used substances (Table 1). Of the 52 036 adolescents without substance use experience, 49 668 (95.4%) were living with their parents and 2368 (4.6%) were not. Compared with nonuser adolescents living with their parents, nonuser adolescents not living with their parents were significantly more likely to be in high school (84.2% vs 47.6%), reside in a rural area (22.1% vs 5.3%), have low socioeconomic status (20.6% vs 11.2%), have smoking experience (5.7% vs 3.0%), and have lifetime alcohol experience (45.0% vs 31.6%; all P < .001). Of the 837 adolescents with substance use experience, 694 (82.9%) were living with their parents and 143 (17.1%) were not. Among ever users, those not cohabitating with parents (vs cohabiting with parents) were more likely to be male (56.8% vs 44.0%), of low socioeconomic status (48.5% vs 17.5%), have lifetime smoking experience (40.3% vs 17.1%), and have lifetime alcohol experience (75.6% vs 59.6%) (all P < .001). We found no statistically significant differences in school level, residential area, or academic achievement between the 2 groups.

Table 1.

Characteristics of Korean Middle and High School Students, by Substance Use Experience and Parental Cohabitation, 2023 Korea Youth Risk Behavior Survey (KYRBS) (N = 52 880).^a

Characteristic	Nonuser (n = 52 036)			Ever user (n = 837)
Characteristic	Living with parents (n = 49 668)	Not living with parents (n = 2368)	P value^b	Living with parents (n = 694)	Not living with parents (n = 143)	P value^b
Sex			.31			.02
Male	25 160 (51.5)	1222 (54.0)		302 (44.0)	79 (56.8)	.02
Female	24 508 (48.5)	1146 (46.0)		392 (56.0)	64 (43.2)
Education level			<.001			.25
Middle school	27 520 (52.4)	472 (15.8)		346 (46.6)	58 (40.2)
High school	22 148 (47.6)	1896 (84.2)		348 (53.3)	85 (59.8)
Region			<.001			.61
Urban	46 107 (94.7)	1760 (77.9)		660 (96.4)	133 (95.5)
Rural	3561 (5.3)	608 (22.1)		34 (3.6)	10 (4.5)
Socioeconomic status^c			<.001			<.001
Low	5804 (11.2)	489 (20.6)		125 (17.5)	66 (48.5)
Middle	22 616 (45.0)	1065 (44.7)		261 (37.5)	39 (23.5)
High	21 248 (43.8)	814 (34.8)		308 (45.0)	38 (27.9)
Academic achievement^d			0.77			.93
Low	16 145 (32.3)	804 (33.3)		287 (41.0)	58 (42.7)
Middle	14 635 (29.5)	700 (29.0)		167 (24.8)	38 (24.6)
High	18 888 (38.2)	864 (37.7)		240 (34.1)	47 (32.6)
Lifetime smoking experience^e
Yes	1488 (3.0)	147 (5.7)	<.001	115 (17.1)	59 (40.3)	<.001
No	48 180 (97.0)	2221 (94.3)	<.001	579 (82.9)	84 (59.7)	<.001
Lifetime alcohol experience^f
Yes	15 647 (31.6)	1102 (45.0)	<.001	419 (59.6)	106 (75.6)	.001
No	34 021 (68.4)	1266 (55.0)	<.001	275 (40.4)	37 (24.4)	.001

Numbers are unweighted counts; percentages are weighted using Korea Youth Risk Behavior Survey (KYRBS) sampling weights to account for the multistage stratified cluster sampling design. Data source: Kim et al.¹⁷

P values were calculated using the Rao–Scott χ² test, with P < .05 considered statistically significant.

Socioeconomic status was assessed by self-reported family economic status on a 5-point scale (highest, mid-high, middle, mid-low, lowest) and recategorized into 3 levels (high: highest and mid-high; middle: middle; low: mid-low and lowest), following previous KYRBS-based studies.¹⁸

Academic achievement was assessed by self-reported school performance on a 5-point scale and recategorized into 3 levels using the same procedure as socioeconomic status.¹⁸

Lifetime smoking experience was assessed by the question, “Have you ever smoked even one or two puffs of a cigarette in your lifetime?” Participants who responded “yes” were classified as having lifetime smoking experience.¹⁸

Lifetime alcohol experience was assessed by the question, “Have you ever had at least one glass of alcoholic beverage in your lifetime, excluding sips for religious purposes?” Participants who responded “yes” were classified as having lifetime alcohol experience.¹⁸

The prevalence of suicidal ideation among nonusers living with parents, nonusers not living with parents, ever users living with parents, and ever users not living with parents was 8.6%, 10.7%, 22.4%, and 28.3%, respectively (P < .001). The prevalence of suicide planning among the 4 groups was 3.4%, 5.5%, 20.4%, and 23.2%, respectively (P < .001). The prevalence of suicide attempts was 3.0%, 6.7%, 31.3%, and 61.9%, respectively (P < .001).

After adjusting for covariates, the AORs for suicidal ideation were 1.40 (95% CI, 1.17-1.68) for nonusers not living with parents, 2.67 (95% CI, 2.10-3.39) for ever users living with parents, and 3.46 (95% CI, 1.81-6.62) for ever users not living with parents, compared with nonusers living with parents (Table 2). For suicide planning, the AORs were 1.92 (95% CI, 1.40-2.63) for nonusers not living with parents, 6.44 (95% CI, 4.94-8.41) for ever users living with parents, and 8.86 (95% CI, 4.77-16.46) for ever users not living with parents. For suicide attempts, the AORs were 2.91 (95% CI, 2.31-3.65) for nonusers not living with parents, 11.04 (95% CI, 8.77-13.91) for ever users living with parents, and 37.92 (95% CI, 24.61-58.45) for ever users not living with parents, respectively.

Table 2.

Association of Substance Use Experience and Parental Cohabitation With Suicidal Ideation, Planning, and Attempts Among Korean Middle and High School Students, 2023 Korea Youth Risk Behavior Survey (N = 52 880).^a

Cohabitation	Suicidal ideation		Suicide planning		Suicide attempt
Cohabitation	OR (95% CI)	AOR (95% CI)	OR (95% CI)	AOR (95% CI)	OR (95% CI)	AOR (95% CI)
Nonuser
Living with parents	1.0 [Reference]	1.0 [Reference]	1.0 [Reference]	1.0 [Reference]	1.0 [Reference]	1.0 [Reference]
Not living with parents	1.29 (1.08-1.54)	1.40 (1.17-1.68)	1.82 (1.35-2.47)	1.92 (1.40-2.63)	2.49 (2.00-3.10)	2.91 (2.31-3.65)
Ever user
Living with parents	3.08 (2.45-3.88)	2.67 (2.10-3.39)	7.55 (5.84-9.76)	6.44 (4.94-8.41)	15.26 (12.25-19.00)	11.04 (8.77-13.91)
Not living with parents	3.84 (2.01-7.37)	3.46 (1.81-6.62)	10.67 (5.71-19.92)	8.86 (4.77-16.46)	55.16 (35.08-86.72)	37.92 (24.61-58.45)

Abbreviations: AOR, adjusted odds ratio; OR, odds ratio.

^aData source: Kim et al.¹⁷

Among adolescents living with parents, substance use was associated with higher odds of suicidal ideation (AOR = 2.34; 95% CI, 1.82-3.00), suicide planning (AOR = 5.47; 95% CI, 4.10-7.29), and suicide attempts (AOR = 8.13; 95% CI, 6.22-10.63) (eTable 2 in the Supplement). Among those not living with parents, AORs were 1.71 (95% CI, 0.85-3.44), 2.68 (95% CI, 1.23-5.86), and 4.94 (95% CI, 2.89-8.45) for suicidal ideation, suicide planning, and suicide attempts, respectively, although the 95% CI for suicidal ideation included 1. Among nonusers, not living with parents was associated with higher odds of all 3 outcomes (AOR = 1.29, 1.62, and 1.89 for suicidal ideation, suicide planning, and suicide attempts, respectively), while we found no significant association among ever users for suicidal ideation, suicide planning, and suicide attempts.

Multiplicative interaction was not statistically significant for any outcome (eTable 2 in the Supplement). On the additive scale, RERI was 0.39 (95% CI, –1.43 to 3.61; P = .76) for suicidal ideation, 1.50 (95% CI, −3.09 to 9.26; P = .63) for suicide planning, and 24.97 (95% CI, 11.33-45.64; P = .004) for suicide attempts.

Discussion

This study examined associations among adolescent substance use, parental cohabitation, and suicidal behaviors. Both factors were independently associated with elevated risk, with the highest odds observed among ever users not living with parents, suggesting that these factors may jointly contribute to suicidal vulnerability.

These findings are consistent with previous studies. Guo et al analyzed nationwide survey data from high school students in the United States and China and reported that adolescents with substance use experience had approximately 1.2- and 1.5-fold higher odds of suicidal ideation and suicide attempts, respectively, than adolescents without such experience.²⁰ Baiden et al also reported that US high school students who had misused prescription opioids were about 1.6 times more likely to report suicidal ideation, planning, and attempts.²¹

Several biological mechanisms may underlie this association. Adolescence is a developmental period during which the prefrontal cortex, responsible for impulse control and emotional regulation, has not yet fully matured.^8,22 Substance use may further impair prefrontal cortex development, exacerbating impulsive behaviors and emotional instability.^7,9 In addition, decreased dopamine receptor availability has been suggested to reduce sensitivity to natural reward stimuli and may lead adolescents to seek stronger stimulation through risky behaviors.^7,9 Substance use may also lead to excessive hypothalamic–pituitary–adrenal axis activation and elevated cortisol secretion, impairing emotional regulation and increasing vulnerability to suicidal behaviors.²³

The associations between substance use and suicidal behaviors differed according to parental cohabitation. Compared with nonusers living with parents, the OR of suicide attempts was approximately 11 in adolescents who used substances and lived with parents, whereas this value was approximately 38 among adolescents who used substances but did not live with their parents, suggesting that parental cohabitation may buffer the relationship between substance use and mental health problems. The markedly elevated odds of suicide attempts observed in ever users not living with parents indicate that this subgroup may represent a particularly vulnerable population in which the 2 risk factors jointly contribute to suicidal vulnerability beyond their independent effects. It may be noted that ever users not living with parents represented only approximately 0.03% of the total sample (n = 143). From a public health perspective, however, identifying subgroups with markedly elevated risk remains a meaningful objective regardless of their prevalence, given that the prevalence of suicide attempts in this group reached 61.9%.

The RERI for suicide attempts was statistically significant and positive, indicating a positive additive interaction between substance use and absence of parental cohabitation. We found no significant additive interaction for suicidal ideation or suicide planning, and multiplicative interaction was not significant across all 3 outcomes. The small number of ever users not living with parents (n = 143) may have limited statistical power to detect interaction for the other 2 outcomes.

Previous studies have indicated that family environment influences substance use risk regardless of residential arrangement. Zhang et al reported that adolescents from 2-parent households had a lower risk of illicit drug use than adolescents from single-parent or nonparent families.²⁴ Hemovich and Crano¹⁰ also found that substance use was lowest among adolescents residing with both parents, whereas adolescents from single-parent households had relatively higher levels of risky behaviors. According to social control theory, parental cohabitation places adolescents in a more supervised environment, reducing exposure to risky behaviors and thereby decreasing vulnerability to suicidal behaviors.^16,25

Limitations

This study had several limitations. First, it was conducted as a cross-sectional design, which did not allow confirmation of temporal relationships. The possibility of reverse causation cannot be excluded, because adolescents already at elevated risk of suicidal behaviors may have been more likely than adolescents at lower risk of suicidal behaviors to engage in substance use. Moreover, the observed associations may partly reflect shared underlying risk factors—such as family conflict, peer difficulties, and social isolation—that contribute to both substance use and suicidal behaviors, and the influence of such unmeasured confounders cannot be excluded^26,27; future longitudinal studies are warranted. Second, all variables, including substance use and suicidal ideation, planning, and attempts, were measured through self-report, which may have introduced misclassification. However, because participants were unaware of the study objectives when completing the survey, differential over- or underreporting according to substance use status was unlikely, and any resulting bias may have been directed toward the null. Third, the survey items used in this study assessed substance use by providing examples of drugs but did not capture more detailed aspects such as the types of substances or frequency of use, severity, or polysubstance use patterns. Although self-reported lifetime drug use based on a single item has demonstrated adequate stability in large-scale adolescent surveys,^28,29 reliance on a single-item measure may have underestimated the complexity and variability of substance use behaviors, as such approaches have been shown to yield lower prevalence estimates than more detailed multi-item assessments.³⁰

Fourth, parental cohabitation was measured only by whether adolescents were currently living with their parents, without reflecting the qualitative aspects of family functioning. Nevertheless, considering the developmental characteristics of adolescence, whether or not adolescents actually cohabited with their parents appeared to be meaningfully associated with substance use and suicidal ideation, planning, and attempts. In addition, the limited number of ever users not living with parents (n = 143) may have reduced statistical power to detect interaction, and larger studies are warranted. Fifth, because this study was conducted using a nationally representative sample of Korean adolescents, caution is warranted when generalizing these findings to other cultural contexts. Nevertheless, the protective role of parental monitoring against adolescent suicidal behaviors has been reported consistently across diverse cultural settings.³¹

Strengths of this study include a large nationally representative sample and anonymous self-administration, which may have reduced reporting bias.

Conclusion

These findings suggest the need for integrated public health interventions that simultaneously address substance use and family structure. School-based programs incorporating Screening, Brief Intervention, and Referral to Treatment may provide a structured approach to identifying adolescents with both substance use and elevated suicidal risk at an early stage, allowing for risk-stratified responses ranging from brief intervention to specialist referral.^32,33 For adolescents not living with parents, family-based interventions may be structurally limited. In such cases, the protective role of parental cohabitation may be partially substituted by supportive adults—such as school counselors, residential staff, or social workers—who maintain consistent monitoring and daily contact with adolescents.³⁴ Establishing environments in which such figures can provide continuous oversight, particularly in dormitories and child welfare facilities, may be a practical intervention strategy.

Supplemental Material

sj-docx-1-phr-10.1177_00333549261464956 – Supplemental material for Association Between Substance Use Experience and the Risk of Suicidal Behaviors Among Adolescents Based on Parental Cohabitation, Korea, 2023

Supplemental material, sj-docx-1-phr-10.1177_00333549261464956 for Association Between Substance Use Experience and the Risk of Suicidal Behaviors Among Adolescents Based on Parental Cohabitation, Korea, 2023 by Eunseok Oh, Hyunsuk Jeong, Woolim Ko and Hyeon Woo Yim in Public Health Reports®

Footnotes

ORCID iD

Hyunsuk Jeong, PhD

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data analyzed in this study are publicly available from the Korea Disease Control and Prevention Agency (KDCA) KYRBS website ().

Supplemental Material

Supplemental material for this article is available online.

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