Drug harm prevention needs among adolescents in Aotearoa New Zealand: findings from the Youth19 Survey

Drug use (including tobacco, alcohol and illicit drugs) is a leading cause of premature death, health loss and health inequities globally.^1,2 In Aotearoa New Zealand (hereafter Aotearoa), tobacco, alcohol and illegal drug use accounts for nearly 9%, about 4% and just over 2% of total health loss respectively.² Drug use generally begins during adolescence¹ and early uptake is a predictor of long-term health and social problems, including substance use disorders in adulthood.³ The social and economic costs of drug harm to people, their families and communities are profound, hence drug harm prevention is an important population health issue in Aotearoa.

Effective prevention and early intervention have the potential to reduce drug-related suffering across the lifecourse and reduce pressure on health and social services.^3,4 This study explores drug harm prevention needs among adolescents in Aotearoa. We define “drug harm prevention” as organised efforts using the full spectrum of interventions at multiple levels (Figure 1) to a) reduce or delay drug use, b) mitigate the negative impacts of drug use, and c) support young people to cut down or stop drug use.

View Figure 1–3, Table 1–5.

Our conceptualisation of drug harm prevention acknowledges that the environments in which young people live, learn and play influence their drug use. For example, widespread availability and marketing of e-cigarettes, tobacco and alcohol are associated with increased use by adolescents.⁵ At the individual level, adolescents engage with drug use for many reasons including curiosity, pleasure and as a coping mechanism.⁶ Reasons for use can affect when and how drugs are used, and the risk of harm. For example, drug use at a young age is often associated with trauma or psychosocial difficulties and used as a coping mechanism;⁷ harm tends to be greater when drugs are used as a coping mechanism because the dosage and frequency of use tend to be higher.^8,9

In Aotearoa, the collective trauma of colonisation and its intergenerational effects are important contextual factors that contribute to higher risk of drug harm among Māori and Pacific adolescents.^10,11 Structurally privileged groups, including Pākehā (New Zealanders of European descent), have lower exposure to proximal risk factors for adolescent drug use (e.g., experiences of interpersonal racism, social exclusion, exposure to alcohol marketing, sexual abuse, family violence, parental drug use) compared to Indigenous peoples, migrants, low-income communities and those who identify as lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQ+).^12–14

Although adolescent drug use in Aotearoa has generally declined over the past two decades, significant concerns remain. Prevalence of tobacco and alcohol use among secondary students is now lower than in the early 2000s, but inequities remain entrenched, reflecting the ongoing impacts of colonisation and broader structural and commercial determinants of health.^10,15 The rapid uptake of nicotine-containing e-cigarettes since 2018 exemplifies the challenge that new and emerging substances pose, with daily use reported by 10% of Year 10 students in 2022, and particularly high rates among Māori youth (22%) compared with Pacific (14%) and Pākehā (8%).¹⁶ Despite declines, alcohol and cannabis use remain prevalent by international standards; in 2019, 44% of Year 13 students reported recent binge-drinking, and nearly a quarter of high school students had tried cannabis—both substances linked to adverse mental health and educational outcomes.¹⁷ Evidence suggests a substantial health burden from illegal drug use among young people, with risks heightened by early initiation and polysubstance use.^18,19 These patterns underscore the urgent need for youth-specific drug harm reduction strategies, particularly those addressing systemic inequities.

The aim of this study is to inform policy and practice by investigating drug harm prevention needs among secondary students in Aotearoa, and updating and extending previous Aotearoa research. Previous studies have established high, inequitable and growing levels of foregone healthcare among adolescents in Aotearoa,^20,21 yet recent investigation of unmet need for tobacco, alcohol and other drug services, by demographic sub-group, is a gap. Further, young people’s own concerns about their drug use have not been explored, except for alcohol use,²² and exploration of patterning of drug use by demographic factors has also been limited to date.

Our study focusses on four drugs—e-cigarettes, tobacco, alcohol and cannabis—and investigates five indicators: prevalence of 1) past month use; 2) heavy use; 3) worry about use, 4) desire to cut down or quit, and 5) reported difficulty getting help to stop tobacco, alcohol or other drug use. Our investigation stratifies these indicators by socio-demographic variables to identify priority sub-groups, where need may be greater, and to better understand this issue for rangatahi Māori (Māori youth), as tangata whenua (Indigenous people of Aotearoa).            

Methods

This study is a secondary analysis of data from Youth19, the latest Youth2000 survey on the health and wellbeing of secondary school students aged 13–18. Detailed methods, participant characteristics and ethical approval details are reported elsewhere.²³

We focussed on the drugs most commonly used by adolescents and for which data were readily available: e-cigarettes, tobacco, alcohol and cannabis.

Survey design

Youth19 used a two-stage clustered sampling design with randomly selected schools and, within these, randomly selected students in three regions: Te Tai Tokerau (Northland), Tāmaki Makaurau (Auckland) and Waikato, an area that includes 47% of the secondary school population of Aotearoa. Data were collected in 2019, and the total number of respondents was 7,721. The survey included questions about home, school and community life, health behaviour, health status and access to healthcare services.

Measures

“Past month use” of e-cigarettes, tobacco, alcohol and cannabis, was based on self-reported use in the past 4 weeks.

“Heavy use” was defined with the understanding that any drug use can harm adolescents, and heavier use increases this risk. For alcohol, “usually consuming five or more drinks per occasion” was the indicator used, based on evidence that binge drinking is associated with elevated risk of acute alcohol harm.^13,24 The data available did not allow us to use other established measures of hazardous drinking (e.g., AUDIT [Alcohol Use Disorder Identification Test] score ≥8, or drinking over Ministry of Health guidelines). For e-cigarettes and tobacco, heavy use was defined as using weekly or more often, given this level of use puts people at high risk of nicotine addiction²⁵ and greatly increases the risk of health, social and financial harm over the lifecourse.²⁶ For cannabis, heavy use was defined as using weekly or more often, as frequent use in this age group is associated with immediate and long-term negative impacts.^27,28

“Worried about use” was based on the question “Do you worry about doing any of these things: a) cigarettes, b) vaping, c) alcohol, d) marijuana”, with responses of “a lot”, “some” and “a little” grouped as an affirmative response.

“Desire to cut down” was based on responses to survey questions “Would you like to cut down or give up on any of these things?” and “Have you ever tried to cut down or give up any of these things?” In preliminary analysis, we found that responses were highly correlated, suggesting these two questions are measuring the same underlying construct (i.e., desire to cut down). Therefore, we combined these variables (using “or”) to simplify reporting.

“Difficulty getting help” was based on responses to the survey question “In the last 12 months, have you had any difficulty getting help for any of the following” and the specific sub-questions “Help with stopping smoking” and “Help with stopping drug or alcohol use”. Response options were “yes” or “no” for each.

Demographic variables were: sex (male, female), age (<16, 16+), ethnic group (Māori, Pacific, non-Māori/non-Pacific), LGBTQ+ status (yes, no), locale (major urban, small town, rural), region (Te Tai Tokerau, Tāmaki Makaurau, Waikato) and neighbourhood socio-economic deprivation (least, medium, most) based on the New Zealand Index of Deprivation 2018.

Analysis

Analysis was conducted using R (The R Foundation for Statistical Computing version 4.1.3). Data were initially weighted using inverse probability of selection weights. Then, for prevalence estimates to better represent the population from which the sample was drawn, generalised raking²⁹ was used to correct for non-response and to calibrate the results to the regional secondary school population.³⁰

We used descriptive statistics to calculate lifetime and past month prevalence for each drug. Among past month users, we estimated the prevalence of 1) heavy use, 2) concern about use, and 3) desire to cut down, overall and by demographic group, using weighted proportions.

To quantify difficulty in getting help, we calculated 1) the proportion of past month tobacco users and secondary students overall who reported difficulty getting help to stop smoking, and 2) the proportion of past month alcohol or cannabis users, and secondary students overall, who reported difficulty getting help to stop alcohol or other drug use. We used logistic regression to examine differences in reported difficulty across demographic groups, presenting results as odds ratios and p-values.

Results

Lifetime and past month drug use

Ever use of e-cigarettes (38%) and alcohol (47%) was relatively common, whereas ever use of tobacco (15%) and cannabis (19%) was less prevalent (Figure 2). Past month use was much less prevalent than ever use for each drug.

The remaining results focus on secondary school students who used e-cigarettes, tobacco, alcohol or cannabis in the past month.

E-cigarettes

Among those who had used e-cigarettes in the past month, 59% reported vaping weekly or more often, half (50%) reported concern about their e-cigarette use and about a third (34%) wanted to cut down or stop (Table 1). Findings for demographic sub-groups are provided in Table 1. Desire to cut down or stop was highest among those living in areas with the least socio-economic deprivation (40%).

Tobacco

Among those who had used tobacco in the past month, 63% reported smoking weekly or more often, 63% reported concern about their tobacco use and two out of three (66%) wanted to cut down or stop (Table 2). Findings for demographic sub-groups are provided in Table 2. Heavy use differed significantly by ethnic group.

Alcohol

Among those who had used alcohol in the past month, almost half (46%) reported they usually drank five or more alcoholic drinks per drinking occasion, 45% were worried about their alcohol use and 18% wanted to cut down or stop. Findings for demographic sub-groups are provided in Table 3. Pacific students were least likely to have used alcohol in the past month (19%), but among past month users were most likely to drink heavily (65%). Prevalence of heavy use differed by age and sex as well as ethnicity. Those living in areas of high socio-economic deprivation were more likely to report wanting to cut down or stop (26%) compared with those in the least deprived areas (15%).

Cannabis

Among those who had used cannabis in the past month, 44% reported using weekly or more often, about half (51%) worried about their cannabis use and 31% wanted to cut down or stop. Findings for demographic sub-groups are provided in Table 4. Heavy use was higher in neighbourhoods with high socio-economic deprivation (57%) than in the least deprived areas (35%).

Socio-demographic patterning

Prevalence of past month use was markedly lower among younger students (under 16 years) for all drugs. Yet younger students who used tobacco or cannabis in the past month were as, or more, likely than older students to use those drugs heavily. Sex differences in prevalence of past month use were generally small, but prevalence of heavy use was often higher for males than females. Differences by ethnic group were marked, whereas differences between LGBTQ+ and non-LGBTQ+ were generally small, except past month tobacco use.

For most drugs, prevalence of past month use was lower in urban areas than in small towns or rural areas, though differences did not always reach statistical significance.

Among past month users, heavy use was generally more prevalent among students in the most socio-economically deprived areas (i.e., less affluent) compared with the least socio-economically deprived (i.e., more affluent). E-cigarette use was the exception; differences did not reach statistical significance, but there was a trend towards higher prevalence of use and heavy use in neighbourhoods with the least socio-economic deprivation.

Worry about use

Those who used tobacco in the past month were most likely to be worried about their use (63%), followed by cannabis (51%), e-cigarettes (50%) and alcohol (45%) (Figure 3). Prevalence of worry did not necessarily correspond with prevalence of heavy use or desire to cut down.

Desire to cut down or stop

Desire to cut down or stop was highest for tobacco (66%) and markedly lower for e-cigarettes (34%) and cannabis (31%). Participants who used alcohol (18%) were the least likely to report desire to cut down (Figure 3). There was a trend towards higher prevalence of desire to cut down among Pacific students and those living in areas of high socio-economic deprivation for most drugs, though differences did not reach statistical significance.

Difficulty getting help

The proportion who reported difficulty getting help to stop smoking in the previous 12 months was 19% among those who smoked tobacco in the past month (Table 5), and 1.7% (95% confidence interval [CI] 1.2–2.4) among secondary school students overall (data not shown). Differences between socio-demographic groups did not reach statistical significance, but the results suggest that younger, LGBTQ+, Māori and Pacific students may be more likely to have difficulty accessing help to stop smoking.

The proportion who reported difficulty getting help to stop alcohol or other drug use was 5% of those who reported past month alcohol and/or cannabis use (Table 5) and 2% (95% CI 1.6–2.5) of secondary students overall (data not shown). Age and ethnic group were significantly associated with difficulty in accessing help, with younger, Māori and Pacific students more likely to report difficulty accessing help to stop alcohol or other drug use. Other differences did not reach statistical significance, but the findings suggest LGBTQ+ students and those living in rural areas may also be more likely to have difficulty accessing help to stop alcohol and other drug use.

Discussion

Our investigation highlights drug harm prevention needs among adolescents in Aotearoa. Although most secondary students reported they did not use e-cigarettes, tobacco, alcohol or cannabis, the prevalence of past month use (10%, 4%, 27% and 8% respectively) is concerning, especially given many reported heavy use. Many past month users reported concern about their own use and desire to cut down or stop, particularly students who smoked tobacco. This is a positive finding, indicating a promising opportunity to support behaviour change. However, some participants reported difficulty getting help. We found need was not evenly spread; Māori, Pacific and LGBTQ+ youth, those aged under 16 years and those living in small towns, rural areas and the most socio-economically deprived communities had higher needs on many indicators. Our findings suggest these groups should be prioritised for prevention and early intervention. Findings differed by drug and indicator, highlighting the benefit of using multiple indicators to gain a fuller understanding of drug harm prevention needs in this age group.

Our findings should be interpreted within Aotearoa’s social context, where the acceptability of different drugs varies. Less socially accepted substances (e.g., tobacco, cannabis) were less commonly used than more accepted ones (e.g., alcohol, e-cigarettes). Notably, heavy use did not always align with high levels of worry or desire to cut down, possibly reflecting societal attitudes. For instance, worry and desire to cut down was generally lower for alcohol, a drug with high social acceptability, than for tobacco, which has become increasingly socially unacceptable in recent years.³¹ Relatedly, the relatively low proportion of students reporting difficulty accessing help to stop alcohol or drug use may reflect low levels of concern and help-seeking, rather than an abundance of appropriate and accessible support services.

In addition to permissive attitudes to some drugs, other barriers to help-seeking identified in previous research include lack of awareness of services, stigma, concerns about confidentiality and past experiences of racist or judgemental service providers.^20,32–34 Because young people, particularly those from under-served communities, often do not seek help for drug issues, our findings about difficulty getting help (specifically “no” responses) are challenging to interpret but are likely to underestimate need.

Our findings align with previous studies that have identified significant unmet health need among Māori, Pacific and LGBTQ+ students, and those living in neighbourhoods with high socio-economic deprivation and in rural areas.^20–22 In addition, we have identified significant unmet need for drug harm prevention among younger students (those under 16 years old) and those living in small towns (population 1,000–10,000 people). Younger adolescents are more vulnerable to drug harm than older adolescents, and their drug use may be linked to complex psychosocial needs.^3,7 Accessible interventions for children under 16 years should be a priority, alongside other under-served groups. Whānau (family) based interventions may be needed, particularly for this younger age group.

Effective population-based measures to prevent or reduce tobacco and alcohol use in young people are well established,⁴ and while Aotearoa has a history of strong tobacco control, it lags behind other countries in alcohol control implementation.³⁵ Evidence is more limited for effective school-based programmes, family programmes and brief interventions to reduce drug use in adolescents;⁴ these are important areas for future research. Our study highlights the under-served populations such interventions should be tailored for. Previous research on barriers such as stigma, privacy concerns and mistrust—particularly among marginalised youth—highlights the importance of co-designed, culturally safe, youth-centred services.^20,32 Digital interventions show promise,³⁶ but there is a need to adapt and test these in Aotearoa.

The strengths and limitations of this study should be considered when interpreting the findings. Strengths include a large, diverse sample and a survey design aimed at achieving a representative sample of secondary school students. However, drug use may be underestimated, as youth with poor school attendance or outside the school system—who may be at greater risk of drug use^37,38—were likely under-represented. As the survey was regional, findings may not generalise to other regions. E-cigarette findings reflect a period before cheap, high-nicotine vapes were widely available. The survey did not include questions about access to vaping cessation support, limiting analysis in this area. Continued research is needed to understand adolescent e-cigarette use and support needs in a rapidly evolving product and regulatory environment. Prevalence of “difficulty getting help” may be underestimated due to low help-seeking in this age group, and our findings should be considered alongside other research on help-seeking and unmet health needs in this population.^20,32–34 While the data are now somewhat dated, Youth19 remains the most recent comprehensive survey of adolescent drug use, attitudes and health access in Aotearoa.

Conclusions

Many adolescents are concerned about their drug use and want to reduce it, yet getting appropriate help can be difficult. These findings suggest there are promising opportunities for drug harm prevention in Aotearoa. Our research identifies under-served populations including Māori, Pacific people, LGBTQ+ youth, younger adolescents and those living in small towns, or rural or socio-economically deprived areas. Addressing root causes of inequity is key to reducing drug-related harm and improving outcomes. Prevention action should centre the needs of under-served groups and span the intervention continuum, from upstream efforts to address the commercial, structural and social determinants of health, to population-based policy interventions, and effective early intervention for young people who want to reduce their drug use. Although evidence-based policy interventions exist, Aotearoa has not fully adopted them; weak alcohol control is a notable shortfall to be addressed. Prioritising research and responsive support for youth and their whānau will help Aotearoa to prevent drug harm before it takes hold, thereby building healthier futures and stronger communities.