Kids these days — in particular 18-24 year-olds — are giving up cigarettes in favor of more refined ways of upsetting their parents. Although rates of young adult cigarette use have dropped significantly in recent years to just 10%, marijuana use has crept up to about 20% (p. 23). Meanwhile, e-cigarettes have exploded in popularity even among high-school students, and although binge-drinking rates haven’t grown, they remain high: between 35 and 40 percent among young adults (p. 36).

This isn’t to say that youth cigarette use is no longer a problem — in fact, if current rates persist, 1 in 13 of America’s youth will die early from a smoking-related illness. Even so, advocacy on the deadly effects of habitual smoking must be counted among the greatest public health successes of recent decades, an effort without which that alarming number would be even higher.

Smoking, excessive drinking, and marijuana use all jeopardize health, but by how much? The CDC estimates that regular smoking shaves an average of 10 years off your life expectancy, and a recent meta-analysis shows that excessive drinking may lead to average losses of anywhere from 6 months to 5 years. Though data on marijuana use is less developed, the drug causes a host of adverse physical and psychological effects, which are pronounced in youth and affect quality of life often more than longevity.

Given the threat these habits pose to public health, it’s important to understand what motivates young adults to smoke and drink, as well as what might deter them. I’ll first assess the need for information campaigns by exploring whether young substance-abusers are aware of the risks they run. Then, I’ll judge the success of public health advocacy to date by reviewing recent trends in overall youth perception of risk for each of these substances.

The Will or the Way?

It turns out tobacco, binge-drinking, and marijuana are pretty harmful, albeit to varying degrees — that’s not news. Why then are so many people continuing to abuse these substances, and what can be done about it? As a first foray, I located some survey data on 18-26 year-olds’ health habits. The study tracked individuals from youth into young adulthood in 5 waves. Wave 3 data was collected in 2001-2, when participants were between 18 and 26 years old.

Although the data’s from 2002, it’s particularly rich, offering thousands of individual-level variables that give insights into young adults’ daily lives and opinions. I’ll use it to isolate different groups of substance users and compare their attitudes and lifestyles to those of their peers, in the hope of answering some key questions:

• To what extent has advocacy on each different substance abuse issue reached affected audiences?
• Do users have an action problem (“the will”) or an information problem (“the way”)?
• In particular, do smokers/drinkers/stoners know that their habit is bad for them, or does society need to invest more in advocacy and information-sharing?

Cigarettes

I first investigated the relationship between smoking cigarettes and self-reported health status. Given that cigarettes have received the lion’s share of public health scrutiny, I figured this category of substance users would be most likely to understand itself as unhealthy. Indeed, as of 2002, 18-26 year-olds are on average half as likely to feel healthy if they regularly smoke cigarettes (p < .0001).¹

Interestingly, since the more severe effects of cigarette use don’t manifest until later on in life, this difference in self-reported health status primarily reflect respondents’ knowledge that cigarettes are bad and will in the future lead to serious health problems. Even by 2002, therefore, cigarette-users appear to have known the risks involved with their habit. Many of them had an action problem, rather than a problem of information, due to cigarettes’ highly addictive nature. Advocacy largely succeeded in reaching its target population. That generation of smokers, now between 35 and 43, is still at greatest risk of smoking cigarettes, showing just how resilient a nicotine addiction can be even when addicts are aware of the harms.

Marijuana

Next, I explored whether recreational marijuana users report similar relative health deficiencies. Marijuana differs from cigarettes in a couple of key ways: for one thing, marijuana has more immediate health effects than cigarettes, so an actual health effect could be reflected in self-reporting for marijuana-users; on the other hand, public advocacy on marijuana’s risks isn’t as strong as that developed around tobacco products. Yet it turns out that, in 2002, 18-26 year-olds average 30% lower odds of self-reporting as healthy if they smoke marijuana (p < .0001).

Since cigarette use generally takes years to register notable health costs, the interpretation of the use–reported health relationship was simpler. For marijuana, however, some portion of the drop in self-reported health status likely comes from genuinely poorer health at the time of the survey, while the rest again comes from knowing that the drug is harmful. University of Michigan’s young adult survey results suggest that knowledge of risk is indeed one contributor to that statistic — about half of 12th graders in 2002 considered regular marijuana use of “great risk.”

Alarmingly, that fraction has dropped to just 31% as of 2016, and undoubtedly the proportion of marijuana users who understand the drug’s risks is even lower. Once informed, action may be difficult for those 10% who become addicted. That said, marijuana-users’ primary barrier to behavioral change is informational, unlike the case for young cigarette-users.

In fact, a recent study show that the public consistently underestimates marijuana’s risks relative to the scientific community’s assessments. Many today believe, without evidence, that recreational marijuana use can alleviate a number of other health concerns. Others wrongly believe that marijuana can’t cause addiction.

In reality, recreational marijuana use results in an array of adverse health outcomes. According to the CDC, marijuana seriously threatens neurological health and development in the short- and long-term, primarily impacting memory, attention, and learning ability. The drug may put users at increased risk of deadly cardiovascular disease, and the smoke produced often worsens lung health.

The United States needs a sea-change in its thinking about marijuana use to combat this growing information problem. It must go beyond the “Just Say No” campaigns of the ’80s and ’90s. Parents, educators, and community leaders must call out the specific drugs kids are most likely to abuse and least likely to understand — namely marijuana –, especially as state lawmakers increasingly forfeit these decisions to our young adults.

Alcohol

Finally, I compared self-reported health between binge-drinkers and the rest of the young adult population. Binge-drinking is more akin to smoking marijuana in that it’s not as addictive as the nicotine in cigarettes. Only about 10% of excessive drinkers would meet the criteria for alcohol dependence — the same rate of addiction to marijuana among users. Yet binge-drinking is more like cigarette use in that serious health effects are usually quite delayed. Therefore, lower self-reported health among binge-drinkers will mostly reflect knowledge of the dangers of excessive drinking, rather than genuinely worse health, in our 18-26 year-old population.

As of 2002, however, binge-drinkers self-report just as healthy as others on average. The fact that binge-drinking doesn’t seem to affect young adults’ view of their own health is perhaps the most troubling statistic in all of this, indicating a severe underappreciation of the myriad health risks involved. In the long-run, these include memory and learning problems, a number of deadly diseases of the heart and liver, and various cancers, not to mention the increased immediate risks of car crashes, STDs, and sexual assault.

In the rush to stem the use of tobacco and other potent drugs, alcohol abuse among young adults has excited less public censure, despite being such a common and dangerous form of substance abuse. These data suggest that educators and mentors need to show kids not just blackened lungs, but scarred livers too.

Risk-Perception over Time

It was helpful to see how substance users in particular think of their own habits — on the whole, cigarette-users have more of an action problem than marijuana- and alcohol-users, whose problem is primarily one of information. Again, however, the data so far has been from 2002. So here’s how U.S. 12th graders, whether they use the substance or not, have thought about the risks of these activities over time (with a vertical line marking 2002, the original study year):

To be clear, these data estimate attitudes on substance use across the U.S. youth population — not simply among those who use these drugs –, but the overall trend in risk-perception is still informative. Most notably, skepticism toward marijuana use among young adults has precipitously declined since the 2002 survey was collected, indicating serious setbacks for public health advocacy on the legitimate dangers of regular marijuana use.

Meanwhile, perception of risk for binge-drinking and smoking cigarettes has crept slightly upward in recent years, though significant proportions of young adults today still believe these activities pose no great risk (24% regarding cigarettes, and a whopping 51% regarding heavy alcohol use).

More Talk, More Action

Taken together, these statistics underscore the need for expanded public health advocacy particularly on the issues of marijuana and excessive drinking — the one in vogue, the other too old to excite much antipathy. And even as tobacco use declines, the gamut of smoking substitutes like JUUL and other e-cig varieties are rapidly rising in popularity, despite their own host of health risks.

U.S. public health still has serious problems of information and advocacy, and these recent innovations have only exacerbated misinformation about the substances youths subject their bodies to. In addition, new and old product manufacturers alike continue to prey on ignorance and cleverly market to at-risk youth. These aren’t “bad kids” — many young Americans simply haven’t been shown the dangers of substance abuse and the way to a more fulfilling life in its absence.

Debates over legalization, marketing regulation, and individual product taxes will continue, but in the meantime, the guardians of American communities — those parents, teachers, pastors, coaches, and other mentors who know better and have influence — should equip themselves and their loved ones with the evidence on these risky behaviors so their kids and mentees can make an informed decision before stepping into a life of substance abuse and addiction.

¹ This interpretation falters if any covariates of the given use behavior also impact self-reported health. Though I can’t rule out this possibility, including controls for a variety of demographic factors and indicators for the other use behaviors barely budges the point estimates.