Impact of Perceived Risk and Friend Influence on Alcohol and Marijuana Use Among Students

Abstract

We performed a secondary analysis of Adolescent Health Risk Behavior Survey data (N = 937), examining associations between lifetime alcohol and marijuana use with intrapersonal (i.e., risk perceptions) and interpersonal (e.g., peer approval and behavior) factors. Multinomial and binary logistic regression analyses contend students reporting lifetime alcohol use—compared to students who had never used alcohol or marijuana—perceived lower alcohol risk (p < .001), higher friend drinking approval (p < .001), and greater friend drinking (p = .003). Using both alcohol and marijuana in one’s life was associated with being in public schools (p = .010), higher grade levels (p = .001), lower perceived alcohol (p = .011) and marijuana use risk (p = .003), higher friend approval of alcohol (p < .001) and marijuana use (p < .001), and believed more friends used alcohol (p < .001). Compared to lifetime alcohol only, perceived friend academic performance decreased the risk of lifetime alcohol and marijuana use (p = .043). Findings are beneficial to school nurses with students experiencing effects associated with substance use.

Keywords

alcohol/tobacco/drug use prevention health education middle/junior/high school quantitative research school nursing

Alcohol is the most frequently used substance among adolescents in the United States. Approximately 10% of 8th graders and 35% of 12th graders report past month alcohol use (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 2016). Underage alcohol consumption has been linked with a variety of negative consequences, such as poor academic performance (El Omari et al., 2015), lower educational aspirations (Barry, Chaney, & Chaney, 2011), unintentional injuries (Hingson & Zha, 2009), and difficulties with logical reasoning (Thoma et al., 2011). The insidious nature of alcohol is even more concerning, given it has been identified as a gateway to illicit substance use, such as marijuana (Barry et al., 2016; Kirby & Barry, 2012). Similar to alcohol use, marijuana is associated with several negative consequences, such as decrements in cognitive functioning and cardiovascular diseases (Hadland & Harris, 2014; Winward, Hanson, Tapert, & Brown, 2014). According to the most recent Monitoring the Future results, an estimated 21% of 12th graders reported smoking marijuana in the past month (Johnston et al., 2016).

Perceived Risk/Harm of Substance Use

Although alcohol and marijuana use have been linked to an array of health and social problems, adolescents continue to use these substances. A low perceived risk/harm of using alcohol and marijuana have been contributing factors influencing adolescent substance use (Hampson, Severson, Burns, Slovic, & Fisher, 2001; Volkow, Baler, Compton, & Weiss, 2014). For example, several decades of research have shown that individuals who perceive marijuana as less risky are more likely to report marijuana use than their counterparts who perceive marijuana as more risky (Johnston et al., 2016). Further, young adults with low perceived risks of alcohol and marijuana co-use are more likely to use alcohol and marijuana on the same day (Yeomans-Maldonado & Patrick, 2015). Thus, it is clear that the perceived risk or harm that adolescents attach to use of alcohol and marijuana are salient factors influencing overall use.

Friend/Peer Influence on Substance Use

One of the underlying factors impacting adolescent substance use behaviors, and the risk/harm adolescents attach to these substances, is interpersonal relationships with friends/peers (Bauermeister, Elkington, Brackis-Cott, Dolezal, & Mellins, 2009; Crosnoe & McNeely, 2008; Deutsch, Chernyavskiy, Steinley, & Slutske, 2015; Tucker, de la Haye, Kennedy, Green, & Pollard, 2014). Because friends are a primary source for socialization (Warr, 2002), friends serve as a main resource in modeling behaviors promoting drinking, smoking, and drug use (Jacobs, Goodson, Barry, & McLeroy, 2016; Vogel, Rees, McCuddy, & Carson, 2015).

School settings and youth groups often frame adolescents’ social contexts and boundaries fostering friend relationships and accentuate the significance of belonging (Bauermeister et al., 2009). Once adolescents join a peer group, they begin to incorporate the group’s norms into their own behavior (Crosnoe & McNeely, 2008), leading adolescents within the same peer or friend group to share ideas, beliefs, and behaviors. Several studies have detailed school and peer groups as substantially influential in both the initiation and continued use of alcohol and drugs (Ennett et al., 2008; Vogel & Barton, 2013; Zimmerman & Vasquez, 2011). Thus, adolescents who socialize with friends/peers who have low perceived substance use risk/harm are themselves at increased likelihood to have lower perceived risk/harm associated with use of licit and illicit substances.

Prevention Imperatives

Given resources for school-based substance use prevention programs are scarce, and maximizing the impact and reach of these resources is paramount, there are researchers who contend alcohol-focused prevention programs should take precedence over interventions which take a polysubstance approach (Barry et al., 2016; Kirby & Barry, 2012). Support for such an approach is grounded in the Gateway hypothesis (Choo, Roh, & Robinson, 2008; D. Kandel, 1975; D. B. Kandel, 2002), which postulates the use of licit substances precedes and results in the initiation of illicit substance use. Prior to adjusting priorities in resource allocation for substance use prevention programs and initiatives in school settings, we contend further investigation is needed. In particular, there is a need for investigations that examine whether there are key underlying influences of drinking and combined alcohol use and illicit substance use, including perceived risk/harm.

Current Investigation

This study examined whether perceived risk of alcohol and marijuana use and perceived risk versus benefits of alcohol use were associated with (1) lifetime alcohol use only and (2) lifetime use of alcohol and marijuana among a sample of middle and high school students. We also assessed whether perceived friend approval of alcohol use, perceived friend approval of marijuana use, perceived friend behavior of alcohol use, perceived friend behavior of marijuana use, and perceived friend academic performance correlated with lifetime alcohol use only and lifetime alcohol and marijuana use.

Method

Design

Data for this investigation are from the local, cross-sectional Adolescent Health Risk Behavior Survey (AHRBS) conducted in one Indiana County. The purpose of the AHRBS was to provide estimates for a wide range of social and environmental factors on adolescent alcohol, tobacco, and other drug use (Smith, McKyer, & Larsen, 2010). This data set has been widely used in previous studies (Diep, McKyer, Smith, Pruitt, & Outley, 2013; Smith, Barry, & Merianos, 2017; Smith, Colwell, Forté, Pulczinski, & McKyer, 2015; Smith & McKyer, 2013; Smith, Warne, et al., 2015; Warne, McKyer, & Smith, 2012). Texas A&M University’s institutional review board approved the present study.

Population/Setting and Sampling Procedure

We performed a secondary analysis of AHRBS data. Our sample included 937 students who attended public and private middle and high schools in Monroe County, IN. A total of 144,705 individuals reside in this county, and 15.9% of this population is under 18 years of age (U.S. Census Bureau, 2015). AHRBS data were collected as part of the Alcohol, Tobacco, and Other Drug Use survey project conducted by the Indiana Prevention Resource Center (IPRC, 2016). The IPRC used a purposive quota cluster sampling technique that was stratified by grade level to select participants. Schools were randomly selected from one district (i.e., corporation) in Monroe County, IN, to participate in the AHRBS, and subsequently, a random sample of classrooms was selected in participating schools. A total of 1,992 middle school and high school students were originally recruited to participate in the ARHBS; and of these, 1,430 completed the survey (71.8% response rate) in their classrooms during regular school time. All survey responses were anonymous. Student participation was voluntary, and they could withdraw at any time. Before completing the AHRBS, all parents consented for their child to participate, and all students gave their assent to participate.

For the purpose of the present study, participants who were missing data on lifetime alcohol use (n = 180), lifetime marijuana use (n = 175), or grade level (n = 219) were omitted. Participants were also excluded for not reporting their sex (n = 206) or one or more of the 13 scale-related items used in the current study (n = 141). Further, participants who reported using marijuana but not alcohol (n = 10) were omitted from analyses. Many participants had missing data for more than one of these variables; thus, the current study’s sample consisted of 937 students in 7th–12th grade.

Instrumentation

Table 1 presents an overview of the AHRBS items used in the present study, which are detailed below. The validity and reliability of the scales employed within the AHRBS instrument have been previously tested and established, and the methodology explicitly outlined previously (Smith et al., 2010). When modified for the purposes of this study, internal consistency reliability coefficients were provided for scales.

Table 1.

AHRBS Survey Item Descriptions.

Measures	Number of Items	AHRBS Item Description	Response Options Used in Present Study
Lifetime alcohol and marijuana use	2 items	Have you ever used…? Alcohol (beer, wine, wine coolers, liquor)? Marijuana (hashish or hash oil)?	Used neither alcohol nor marijuana Used alcohol only Used both alcohol and marijuana
Perceived Risk of Alcohol Use Scale	6 items	If you did the following activities, to what extent do you believe that you would be personally at risk of getting hurt or sick? Drinking beer Drinking wine Drinking whiskey Drinking alcohol (beer, wine, whiskey, liquor) occasionally Drinking any alcohol (beer, wine, whiskey, liquor) at all Drinking five (males)/four (females) or more drinks in a row	0 = no risk at all 6 = very much at risk
Perceived risk of marijuana use	1 item	If you did the following activities, to what extent do you believe that you would be personally at risk of getting hurt or sick? Using marijuana at all	0 = no risk at all 6 = very much at risk
Perceived Risk Versus Benefits of Alcohol Use Scale	4 items	To what extent are the benefits or pleasures provided by each of the following activities greater than the risks associated with it? Drinking beer Drinking wine Drinking whiskey Drinking five (males)/four (females) or more drinks in a row	0 = benefits much greater than the risks 6 = risks much greater than benefits
Perceived friend approval of alcohol use	1 item	How do you think your close friends feel (or would feel) about you doing each of the following thing: Take one or two drinks of alcohol (beer, wine, liquor) occasionally	0 = strongly disapprove 4 = strongly approve
Perceived friend approval of marijuana use	1 item	How do you think your close friends feel (or would feel) about you doing each of the following thing: Use marijuana occasionally	0 = strongly disapprove 4 = strongly approve
Perceived friend behavior of alcohol use	1 item	What percentage of your friends drink alcohol regularly?	0 = 0% 10 = 100%
Perceived friend behavior of illicit drug use	1 item	What percentage of your friends use illicit drugs?	0 = 0% 10 = 100%
Perceived friend academic performance scale	3 items	Most of my friends think that getting good grades is important. Please think about your best friend in this school. As far as you know, rate how much you agree with the following statement: Is interested in school Plans to go to college	0 = strongly agree 4 = strongly disagree

Note. AHRBS = Adolescent Health Risk Behavior Survey.

Lifetime alcohol use and marijuana use

Lifetime alcohol use and marijuana use, our outcome variables of interest, were assessed via 2 questions on the number of times participants used alcohol or marijuana in their lifetime. For each variable, responses (never, 1–5 times, 6–19 times, 20–40 times, and more than 40 times) were dichotomized to indicate lifetime use (i.e., never compared to one or more times) due to the categorical nature of response options and skewedness of participants’ responses. These items were combined to create a 4-category variable indicating participants’ use of these substances. Response categories included used neither alcohol nor marijuana, used alcohol only, used marijuana only, and used both alcohol and marijuana.

Perceived Risk of Alcohol Use Scale

Perceived risk of alcohol use was assessed by a 6-item scale about participants’ perceptions about their personal risk of getting hurt or sick from using alcohol. The 6 items were summed for the scale (range = 0–36; Cronbach’s α = .92). Higher scores indicate higher perceived risk of alcohol use. This scale was adapted from the 10-item Alcohol-Related Risk Perception Scale used in prior research (Smith et al., 2010). The new scale, which consists of 6 items, deviates from the original 10-item version since it only includes items specific to participants’ perceptions about their own personal risk associated with getting hurt or sick from using alcohol and excludes the 4 questions on participants’ perceptions of another person their age getting hurt or sick from engaging in alcohol use (i.e., drinking beer, wine, whiskey, or 5 [males]/4 [females] or more drinks in a row).

Perceived risk of marijuana use

Perceived risk of marijuana use was assessed by 1 item on participants’ perceptions about their personal risk of getting hurt or sick from using marijuana (range = 0–6).

Perceived Risk Versus Benefits of Alcohol Use Scale

The Perceived Risk Versus Benefits of Alcohol Use Scale was assessed by 4 items on perceptions of the benefit-to-risk ratio of drinking alcohol. All 4 items were summed for the scale (range = 0–24; Cronbach’s α = .91). Higher scores indicated perceiving greater risks versus benefits, associated with alcohol. We modified this scale from the original 5-item Perceived Risk Versus Benefits Scale (Smith et al., 2010; Smith, Colwell et al., 2015) by only including alcohol-related risk versus benefits items.

Perceived friend approval of alcohol use

One question assessed perceived friend approval of alcohol use and asked participants to indicate how they think their close friends feel about them taking 1 or 2 drinks of alcohol occasionally (strongly approve to strongly disapprove; range = 0–4).

Perceived friend approval of marijuana use

One question also assessed perceived friend approval of marijuana use and asked participants to indicate how their close friends feel about them using marijuana occasionally (strongly approve to strongly disapprove; range = 0–4).

Perceived friend behavior of alcohol use

One question assessed perceived friend behavior of alcohol use (range = 0–10). Participants provided estimations about the percentage of their friends who drink alcohol regularly (0–100%).

Perceived friend behavior of illicit drug use

One question assessed perceived friend behavior of illicit drug use (range = 0–10). Participants provided approximations for the percentage of their friends who use illicit drugs (0–100%).

Perceived Friend Academic Performance Scale

Students rated how much they agreed and disagreed with 3 items related to perceived friend academic performance. Also called the Peer Academic Performance Scale (Smith et al., 2010; Smith et al., 2015), these 3 items were summed for the Perceived Friend Academic Performance Scale (range = 0–12; Cronbach’s α = .64). Higher scores indicated lower perceived friend academic performance.

Demographic characteristics

Sex, grade level, school level (i.e., middle school and high school), and school type (i.e., public and private) were self-reported.

Data Analysis

All analyses were performed using SPSS (version 22.0). We performed descriptive statistics, χ² analyses, multinomial regression, and binary logistic regression analyses. To examine whether there was a difference between lifetime alcohol and marijuana use and sample characteristics, χ² analyses and one-way analyses of variance were performed. The category of “used marijuana only” was omitted from analyses because of the small number of cases (n = 10). For continuous variables, Tukey post hoc tests were used to identify significant mean differences. To assess the impact demographics (i.e., sex, grade level, school level, and school type), perceived risk of alcohol use and marijuana use, perceived risk versus benefits of alcohol use, perceived friend approval of alcohol use, perceived friend approval of marijuana use, perceived friend behavior of alcohol use, perceived friend behavior of marijuana use, and perceived friend academic performance had on lifetime alcohol use and lifetime alcohol and marijuana use, a multinomial regression analysis was performed. Using neither alcohol nor marijuana served as the referent category for this model. A binary logistic regression analysis was also performed to examine the differences between lifetime alcohol use and lifetime use of alcohol and marijuana based on predictors. Lifetime use of alcohol only served as the referent category for this model.

Results

Sample Characteristics

Sex was nearly equally distributed with 52.2% females and 47.8% males (Table 2). Regarding grade level, there were 14.6% 7th graders, 16.3% 8th graders, 14.4% 9th graders, 13.3% 10th graders, 15.9% 11th graders, and 25.4% 12th graders. The majority of students were in high school (69.1%) and attended public school (75.5%). Nearly half reported never using alcohol in their lifetime (48.2%) and more than one fifth (22.4%) used alcohol 1–5 times, 11.0% used alcohol 6–19 times, 8.8% used alcohol 20–40 times, and 9.6% used alcohol 40+ more times. Most participants (81.9%) reported that they never used marijuana in their lifetime, and 6.7% used marijuana 1–5 times, 3.3% used marijuana 6–19 times, 3.0% used marijuana 20–40 times, and 5.1% used marijuana 40+ more times. A total of 33.6% (n = 315) reported lifetime alcohol use and 18.1% (n = 170) reported lifetime use of alcohol and marijuana.

Table 2.

Sample Characteristics by Lifetime Substance Use.

Item	Total (n = 937)	Neither Alcohol Nor Marijuana (n = 452)	Alcohol Only (n = 315)	Both Marijuana and Alcohol (n = 170)	χ² or F	p
Sex					3.32	.19
Male	47.8%	46.2%	46.7%	54.1%
Female	52.2%	53.8%	53.3%	45.9%
Grade level					184.14	<.001
7th Grade	14.6%	23.7%	8.3%	2.4%
8th Grade	16.3%	24.3%	10.2%	6.5%
9th Grade	14.4%	16.4%	15.9%	6.5%
10th Grade	13.3%	11.9%	15.2%	13.5%
11th Grade	15.9%	11.9%	18.4%	21.8%
12th Grade	25.4%	11.7%	32.1%	49.4%
School level					123.66	<.001
Middle school	30.9%	48.0%	18.4%	8.8%
High school	69.1%	52.0%	81.6%	91.2%
School type					54.92	<.001
Private school	24.5%	33.8%	21.3%	5.9%
Public school	75.5%	66.2%	78.7%	94.1%
Perceived Risk of Alcohol Use Scale	21.56 (±10.33)	27.32 (±8.69)*	17.25 (±8.61)*	13.91 (±8.35)*	208.10	<.001
Perceived risk of marijuana use	4.50 (±1.94)	5.26 (±1.37)*	4.57 (±1.72)*	2.34 (±2.03)*	199.23	<.001
Perceived Risk Versus Benefits of Alcohol Use Scale	17.40 (±6.03)	20.26 (±4.69)*	16.21 (±5.38)*	12.02 (±5.94)*	169.45	<.001
Perceived friend approval of alcohol use	1.39 (±1.34)	0.60 (±0.93)*	1.78 (±1.19)*	2.76 (±1.06)*	294.49	<.001
Perceived friend approval of marijuana use	0.69 (±1.15)	0.24 (±0.67)*	0.51 (±0.85)*	2.25 (±1.32)*	331.64	<.001
Perceived friend behavior of alcohol use	1.21 (±1.54)	0.45 (±0.97)*	1.43 (±1.42)*	2.82 (±1.60)*	224.11	<.001
Perceived friend behavior of illicit drug use	0.48 (±1.02)	0.23 (±0.77)	0.35 (±0.63)	1.39 (±1.56)*	102.26	<.001
Perceived Friend Academic Performance Scale	2.72 (±2.01)	2.26 (±1.80)*	2.92 (±1.96)*	3.59 (±2.27)*	31.32	<.001

*Significant mean differences identified with post hoc tests.

Lifetime Alcohol and Lifetime Use of Alcohol and Marijuana Based on Sample Characteristics

Lifetime alcohol use or lifetime alcohol and marijuana use did not significantly differ based on participants’ sex (see Table 2). Compared to those reporting neither lifetime alcohol nor marijuana use, a significantly larger proportion of students reporting lifetime alcohol use and lifetime use of alcohol and marijuana were enrolled in higher grade levels (χ² = 184.14, p < .001), high school (χ² = 123.66, p < .001), and public school (χ² = 54.92, p < .001).

Lifetime Alcohol Use and Lifetime Use of Alcohol and Marijuana Compared to Nonuse

Results from the multinomial regression, which predicted 63.9% of the variance (Nagelkerke R ² = .64), indicated that compared to those reporting neither lifetime alcohol nor marijuana use, statistically significant predictors of lifetime alcohol use were perceived risk of alcohol use, perceived friend approval of alcohol use, perceived friend behavior of alcohol use, and perceived friend illicit drug use (Table 3). Specifically, for each point higher on the Perceived Risk of Alcohol Use Scale, participants were significantly less likely to have used alcohol in their lifetime (OR = 0.91, 95%CI [0.89, 0.94], p < .001). For each point higher on the perceived friend approval of alcohol use item, participants were significantly more likely to have used alcohol in their lifetime (OR = 1.75, 95%CI [1.43, 2.15], p < .001). Similarly, for each point higher on the perceived friend behavior of alcohol use item, participants were significantly more likely to have used alcohol in their lifetime (OR = 1.38, 95%CI [1.12, 1.71], p = .003). Conversely, each point higher on the perceived friend behavior of illicit drug use item, participants were significantly less likely to have used alcohol in their lifetime (OR = 0.59, 95%CI [0.43, 0.81], p = .001).

Table 3.

Factors Associated With Lifetime Alcohol Use and Use of Alcohol and Marijuana.

Item	Lifetime Alcohol Use Only						Lifetime Use of Alcohol and Marijuana
	β	Standard Error	OR	95% CI			β	Standard Error	OR	95% CI
	β	Standard Error	OR	Lower	Upper	p	β	Standard Error	OR	Lower	Upper	p
Male	—	—	1.00	—	—	—	—	—	1.00	—	—	—
Female	.24	.19	1.28	0.88	1.85	.20	0.42	.29	1.53	0.87	2.67	.14
Grade level (7th–12th)	.18	.10	1.20	0.99	1.44	.06	0.49	.14	1.63	1.23	2.16	.001
Middle school	—	—	1.00	—	—	—	—	—	1.00	—	—	—
High school	.28	.40	1.32	0.60	2.89	.49	−0.64	.62	0.53	0.16	1.79	.31
Private school	—	—	1.00	—	—	—	—	—	1.00	—	—	—
Public school	−.12	.29	0.89	0.51	1.57	.69	1.23	.48	3.43	1.34	8.78	.01
Perceived Risk of Alcohol Use Scale	−.09	.01	0.91	0.89	0.94	<.001	−0.05	.02	0.95	0.91	0.99	.011
Perceived risk of marijuana use	.07	.07	1.08	0.93	1.24	.32	−0.27	.09	0.76	0.64	0.91	.003
Perceived Risk Versus Benefits of Alcohol Use Scale	−.03	.02	0.97	0.93	1.01	.15	−0.06	.03	0.94	0.89	0.99	.03
Perceived friend approval of alcohol use	.56	.11	1.75	1.43	2.15	<.001	0.65	.16	1.91	1.40	2.59	<.001
Perceived friend approval of marijuana use	−.13	.15	0.88	0.65	1.18	.38	0.66	.17	1.94	1.39	2.70	.000
Perceived friend behavior of alcohol use	.32	.11	1.38	1.12	1.71	.003	0.48	.13	1.61	1.24	2.09	<.001
Perceived friend behavior of illicit drug use	−.53	.16	0.59	0.43	0.81	.001	−0.34	.17	0.71	0.51	0.99	.04
Perceived Friend Academic Performance Scale	.00	.05	1.00	0.90	1.11	.96	−0.13	.08	0.88	0.76	1.02	.08

Nagelkerke R ² = .64. Referent group = Neither lifetime alcohol use nor lifetime alcohol and marijuana use.

Compared to those reporting neither lifetime alcohol nor marijuana use, results indicated that statistically significant predictors of lifetime use of alcohol and marijuana were grade level, school type, perceived risk of alcohol use, perceived risk of marijuana use, Perceived Risk Versus Benefits of Alcohol Use Scale, perceived friend approval of alcohol use, perceived friend behavior of alcohol use, and perceived friend behavior of illicit drug use (see Table 3). Specifically, participants were 1.63 times more likely (95%CI [1.23, 2.16], p = .001) to have used alcohol and marijuana in their lifetime if they were in high school and were 3.43 times more likely (95%CI [1.34, 8.78], p = .01) to have used alcohol and marijuana in their lifetime if they attended public school.

Participants were significantly less likely to report lifetime alcohol and marijuana use for each point higher on the Perceived Risk of Alcohol Use Scale (OR = 0.95, 95%CI [0.91, 0.99], p = .011; see Table 3). Participants were also at decreased risk and less likely to have used alcohol and marijuana in their lifetime for each point higher scored on the perceived risk of marijuana use item (OR = 0.76, 95%CI [0.64, 0.91], p = .003). For each point scored higher on the Perceived Risk Versus Benefits of Alcohol Use Scale, participants were significantly less likely to have reported lifetime alcohol and marijuana use (OR = 0.94, 95%CI [0.89, 0.99], p = .03). Regarding each point higher for perceived friend approval of alcohol use, participants were significantly more likely (OR = 1.91, 95%CI [1.40, 2.59], p < .001) to have used alcohol and marijuana in their lifetime. Similar findings were found for each point higher for perceived friend approval of marijuana use, and participants were significantly more likely to have used alcohol and marijuana in their lifetime (OR = 1.94, 95%CI [1.39, 2.70], p < .001). Participants were also significantly more likely to report lifetime alcohol and marijuana use (OR = 1.61, 95%CI [1.24, 2.09], p < .001) for each point scored higher on the perceived friend behavior of alcohol use; for each increase higher the percentage of perceived friend behavior of illicit drug use, participants were less likely to use alcohol and marijuana in their lifetime (OR = 0.71, 95%CI [0.51, 0.99], p = .04).

Lifetime Use of Alcohol and Marijuana Compared to Lifetime Alcohol Use

Compared to participants reporting lifetime alcohol use, logistic regression model results (Nagelkerke R ² = .57) revealed that grade level, school type, perceived risk of marijuana use, perceived friend approval of marijuana use, and perceived friend academic performance were statistically significant predictors of lifetime alcohol and marijuana use (Table 4). Participants enrolled in higher grade levels were 1.37 times more likely (95%CI [1.04, 1.80], p = .02) to have used alcohol and marijuana in their lifetime and were 4.81 times more likely (95%CI [1.90, 12.14], p = .001) to have used alcohol and marijuana in their lifetime if they attended public school.

Table 4.

Factors Associated With Lifetime Use of Alcohol and Marijuana.

Item	β	Standard Error	OR	95% CI
Item	β	Standard Error	OR	Lower	Upper	p
Male	—	—	1.00	—	—	—
Female	0.05	.28	1.05	0.61	1.80	.86
Grade level (7th–12th)	0.31	.14	1.37	1.04	1.80	.02
Middle school	—	—	1.00	—	—	—
High school	−1.27	.67	0.28	0.08	1.04	.06
Private school	—	—	1.00	—	—	—
Public school	1.57	.47	4.81	1.90	12.14	.001
Perceived Risk of Alcohol Use Scale	0.04	.02	1.04	1.00	1.08	.07
Perceived risk of marijuana use	−0.35	.08	0.71	0.60	0.83	<.001
Perceived Risk Versus Benefits of Alcohol Use Scale	−0.02	.03	0.98	0.92	1.04	.48
Perceived friend approval of alcohol use	0.14	.16	1.15	0.85	1.56	.37
Perceived friend approval of marijuana use	0.84	.15	2.30	1.72	3.10	<.001
Perceived friend behavior of alcohol use	0.12	.11	1.13	0.91	1.40	.28
Perceived friend behavior of illicit drug use	0.30	.17	1.35	0.98	1.87	.07
Perceived Friend Academic Performance Scale	−0.15	.08	0.86	0.74	0.99	.04

Nagelkerke R ² = .57. Referent group = Lifetime alcohol use only.

Results indicated that each point higher on the perceived risk of marijuana use item significantly decreased the likelihood of using alcohol and marijuana in their lifetime (OR = 0.71, 95%CI [0.60, 0.83], p < .001; see Table 4). For each point higher on the perceived friend approval of marijuana use item, participants were significantly more likely to have used alcohol and marijuana in their lifetime (OR = 2.30, 95%CI [1.72, 3.10], p < .001). The higher the point scored on the Perceived Friend Academic Performance Scale, participants were at decreased risk for using alcohol and marijuana in their lifetime (OR = 0.86, 95%CI [0.74, 0.99], p = .04).

Discussion

Alcohol and marijuana use and co-use are national public health problems among adolescents. Consistent with existing literature (Johnston et al., 2016), the current study found high rates of lifetime alcohol use (33.6%) and lifetime alcohol and marijuana use (18.1%) among adolescents participating in the AHRBS, with highest rates among students enrolled in higher grade levels. The high rates might be at least partially explained by the perceived benefits of alcohol and marijuana relative to risks. Specifically, we found that students who had low risk perceptions of alcohol use, high perceived friend approval of alcohol use, and high perceived friend behavior of alcohol use had an increased chance of lifetime alcohol use. In addition, students who had low risk perceptions of both alcohol and marijuana, high perceived friend approval of both alcohol and marijuana use, high perceived friend behavior of alcohol use, lower risks associated with alcohol use than benefits and who were enrolled in a public school were associated with an increased chance of lifetime alcohol and marijuana use. Compared to lifetime alcohol use only, students with low perceived risk of marijuana, high perceived friend approval of marijuana use, low perceived friend academic performance, and who were enrolled in a public school had an increased likelihood of reporting lifetime use of alcohol and marijuana. This study extends the literature by focusing on the relationship between the perceived risk of substance use and alcohol and marijuana use among adolescents. The strong relationship between the aforementioned variables suggests that prevention programs, rather than focusing specifically on a particular substance, may have added value if they incorporate strategies that increases adolescents’ perceived risk of substance use.

Public health officials should also consider friends’ perceived substance use versus actual use when developing prevention programs. Prior work suggests adolescents frequently misperceive peer use (Henry, Kobus, & Schoeny, 2011; Lintonen & Konu, 2004), which in turn increases their own use (D’Amico & McCarthy, 2006; D’Amico et al., 2001). Among our sample, factors associated with lifetime alcohol use included perceived friend alcohol approval and use; while factors associated with lifetime alcohol and marijuana use included perceived friend alcohol approval, use, and perceived friend marijuana approval. Reasons for these perceptions could be due to increased opportunities for youth to socialize with more friends/peers who use substances and listen to friends talk about substance use leading to an increased perception that substance use is the norm (D’Amico & McCarthy, 2006). These perceptions are significant to understand and address, as they often lead to increased substance use. Adolescents reported initiation of alcohol if they thought many of their friends were using alcohol in addition to perceived friends’ marijuana use projected marijuana initiation. Furthermore, adolescents’ perception of a substance (e.g., alcohol), may influence early onset of use and elevated use of a different substance such as marijuana (D’Amico & McCarthy, 2006). Therefore, to both prevent and reduce adolescents’ substance use behaviors, coordinated efforts must include multifaceted approaches that seek to establish accurate estimations of peer substance use behaviors, which have been shown to decrease substance use initiation and overall use of alcohol and marijuana (D’Amico & Orlando, 2005; Ellickson, McCaffrey, Ghosh-Dastidar, & Longshore, 2003). These comprehensive approaches include increasing connections and resource sharing at the home, school, and community levels.

Similar to previous research, friend academic performance was a protective factor against substance use among our respondents (Bergen, Martin, Roeger, & Allison, 2005; Mundt, 2011). The protective effect that perceived friend academic performance had was expected in the present study given friends’ behavior has influence on other adolescents’ behaviors (Ennett et al., 2008; Tucker et al., 2014; Vogel & Barton, 2013; Vogel et al., 2015; Zimmerman & Vasquez, 2011). In addition, school-related factors including school connectedness (Bond et al., 2007), perceived self-efficacy to perform well at school, and positive attitudes regarding teachers and the school environment (Brooks, Magnusson, Spencer, & Morgan, 2012) have been reported as protective factors against adolescent substance use. Based on the current study’s results and previous literature, prevention programs should seek to foster a supportive and motivating school environment that leverages teachers, administrators, and students in building school connectedness and the importance of academics. School personnel can be educated on how to create a positive school environment, such as giving positive appraisal to students. Relationship building activities should be offered during school to students and school personnel to foster a supportive and motivating environment.

This study highlights the multiple, intertwined influences on youth substance use and possible leverage points for a multipronged approach to preventing substance initiation and minimizing substance use. In particular, we recommend integrating the aforementioned factors into an intentional “Whole School, Whole Community, Whole Child” (WSCC) approach (Centers for Disease Control and Prevention [CDC], 2015). An expansion of the CDC’s Coordinated School Health approach, WSCC, leverages schools, health agencies, communities, and parents toward a common goal of supporting the health and academics of adolescents. Important factors identified in this investigation, which could be focal points, include several intrapersonal (i.e., perceived risk and feeling supported and safe at school), and interpersonal (i.e., friend substance use, friend academics, and peer approval) factors. Moreover, it is clear that aspects of the school environment (e.g., health education and social and emotional climate) could be coordinated to target these factors. Additionally, engaging the family unit and establishing involvement from the community to further impact these factors would result in decreased substance use initiation as well as frequency and quantity of use.

Limitations

The study limitations should be noted. The AHRBS is cross-sectional in nature, and causal relationships could not be determined. The survey is self-report, and underreporting and overreporting may have occurred. Analyses were limited to the questions provided on the AHRBS instrument. For example, some survey items did not ask about frequency of substance use (e.g., perceived risk of drinking beer). Data were collected from middle and high school students in one Midwestern county, and thus, caution should be used when generalizing findings to other ages and geographical locations. Study analyses omitted participants based on missing data, which may have introduced bias. Readers should consider these limitations when interpreting findings and attempting to generalize them beyond this sample.

School Nursing Implications

Our study found disproportionate rates of lifetime alcohol use only and lifetime alcohol and marijuana use among our sample of 7th- to 12th-grade students. These findings are beneficial to school nurses who might interact with students experiencing physical and psychosocial effects associated with substance use. School nurses play a unique role in the school system and can provide early prevention and intervention by recognizing students who are using substances and referring them to appropriate services. In particular, “Health Services” (e.g., school nurses) are a critical component of the policies, procedures, and practices that can be coordinated in a WSCC approach (CDC, 2015). Overall, this investigation gives additional credence to the powerful impact of friends/peers on the substance use behaviors of adolescents and highlights peer intervention points that school nurses can help leverage within coordinated, targeted approaches.

We found that perceived friend approval and perceived friend use influenced lifetime alcohol use only and lifetime alcohol and marijuana use. Given alcohol is consistently identified as the first substance that adolescents use (Barry et al., 2016; Kirby & Barry, 2012), school nurses are a vital contributor in the planning and implementation stages of school-based interventions seeking to establish accurate perceptions of adolescent drinking behaviors and eliminate misperceptions that influence alcohol initiation. In addition to establishing accurate perceived peer norms, we recommend that prevention programs concurrently seek to link peers’ lack of use with lack of approval and that school nurses educate adolescents on actual rates of use. In other words, prevention programs should establish substance use as uncommon and a behavior that friends do not support. Practically, this could be accomplished by adding disapproval rates to commonly employed norms messaging.

School nurses are well positioned to serve in a central role in the delivery of school health prevention programs focusing on perceived risk and social influences associated with adolescent alcohol and marijuana use. Substance use prevention efforts should be comprehensive in nature and encompass primary, secondary, and tertiary prevention strategies. School nurses and prevention specialists should include students, school personnel, and community partners for a multifaceted approach to reduce alcohol and marijuana use in adolescents. For example, school nurses can train school personnel and community members to identify risk factors and warning signs associated with adolescent substance use. Finally, school nurses should advocate for school-based policies of substance use programming for campuses and school districts that currently lack needed efforts.

Footnotes

Acknowledgments

The authors would like to acknowledge the Indiana Prevention Resource Center for enabling access to schools and participants for this study. The authors also acknowledge Dr. E. Lisako J. McKyer for her guidance and leadership throughout the school engagement, participant recruitment, and data collection processes.

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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