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Adolescent Medicine

Adolescents’ Substance Use and Physical Activity Before and During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Pediatrics

Published Online: May 3, 2021

Original Investigation

Article Information and Disclosures

Benjamin W. Chaffee, DDS, MPH, PhD¹;

Jing Cheng, MD, MS, PhD¹;

Elizabeth T. Couch, RDH, MS¹;

Kristin S. Hoeft, MPH, PhD¹;

Bonnie Halpern-Felsher, PhD²

Author Affiliations

¹Division of Oral Epidemiology and Dental Public Health, University of California, San Francisco, San Francisco
²Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California

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Key Points

Question How have adolescents’ substance use and physical activity behaviors changed under stay-at-home orders related to the COVID-19 pandemic?

Findings In this cohort study of adolescents in Northern California, the overall prevalence of e-cigarette, cannabis, or alcohol use did not meaningfully change with a statewide stay-at-home order, but physical activity declined considerably.

Meaning While youth substance use prevention and cessation support should continue, enhanced efforts to increase physical activity are needed.

Abstract

Importance Stay-at-home policies related to the COVID-19 pandemic could disrupt adolescents’ substance use and physical activity.

Objective To compare adolescents’ substance use and physical activity behaviors before and after stay-at-home restrictions.

Design, Setting, and Participants Ongoing prospective cohort study of tobacco use behaviors among ninth- and tenth-grade students enrolled at 8 public high schools in Northern California from March 2019 to February 2020 and followed up from September 2019 to September 2020. Race/ethnicity was self-classified from investigator-provided categories and collected owing to racial/ethnic differences in tobacco and substance use.

Exposures In California, a COVID-19 statewide stay-at-home order was imposed March 19, 2020. In this study, 521 six-month follow-up responses were completed before the order and 485 were completed after the order.

Main Outcomes and Measures The prevalence of substance use (ie, past 30-day use of e-cigarettes, other tobacco, cannabis, and alcohol) and physical activity (active ≥5 days/week) was compared at baseline and follow-up. A difference-in-difference approach was used to assess whether changes from baseline to 6-month follow-up varied if follow-up occurred after the stay-at-home order, adjusting for baseline behaviors and characteristics. All models were weighted for losses to follow-up using the inverse probability method. Weights were derived from a logistic regression model for having a follow-up response (dependent variable), as predicted by baseline characteristics and behaviors.

Results Of 1423 adolescents enrolled at baseline, 1006 completed 6-month follow-up (623 [62%] were female, and 492 [49%] were non-Hispanic White). e-Cigarette use declined from baseline to 6-month follow-up completed before the stay-at-home order (17.3% [89 of 515] to 11.3% [58 of 515]; McNemar χ² = 13.54; exact P < .001) and 6-month follow-up completed after the stay-at-home order (19.9% [96 of 482] to 10.8% [52 of 482]; McNemar χ² = 26.16; exact P < .001), but the extent of decline did not differ statistically between groups responding before vs after the stay-at-home order (difference-in-difference adjusted odds ratio, 0.84; 95% CI, 0.47-1.52; P = .58). In contrast, being physically active was unchanged from baseline if follow-up was before the order (53.7% [279 of 520] to 52.9% [275 of 520]; McNemar χ² = 0.09; exact P = .82) but declined sharply from baseline if follow-up was after the order (54.0% [261 of 483] to 38.1% [184 of 483]; McNemar χ² = 30.72; exact P < .001), indicating a pronounced difference in change from baseline after the stay-at-home order (difference-in-difference adjusted odds ratio, 0.49; 95% CI, 0.35-0.69; P < .001). Overall in the cohort, reported use of other tobacco, cannabis, and alcohol did not differ meaningfully before and after the order.

Conclusions and Relevance In this cohort, a reduction in e-cigarette use occurred independently of COVID-19 stay-at-home restrictions, but persistent cannabis and alcohol use suggest continued need for youth substance use prevention and cessation support. Declining physical activity during the pandemic is a health concern.

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Article Information

Corresponding Author: Benjamin W. Chaffee, DDS, MPH, PhD, University of California, San Francisco, 3333 California St, Ste 495, San Francisco, CA 94118 (benjamin.chaffee@ucsf.edu).

Accepted for Publication: February 3, 2021.

Published Online: May 3, 2021. doi:10.1001/jamapediatrics.2021.0541

Author Contributions: Dr Chaffee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chaffee, Couch, Hoeft, Halpern-Felsher.

Acquisition, analysis, or interpretation of data: Chaffee, Cheng, Hoeft.

Drafting of the manuscript: Chaffee, Halpern-Felsher.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chaffee, Cheng.

Obtained funding: Chaffee, Halpern-Felsher.

Administrative, technical, or material support: Couch, Halpern-Felsher.

Supervision: Chaffee.

Conflict of Interest Disclosures: Dr Chaffee reports personal fees from Westat for consulting related to design and data analysis of studies of tobacco and oral health. Dr Halpern-Felsher reports personal fees from e-cigarette litigation outside the submitted work and is an unpaid scientific advisor and expert witness regarding some tobacco-related policies. No other disclosures were reported.

Funding/Support: Support was from the National Institutes of Health (grant U54 HL147127).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funder.

Additional Contributions: We thank Manali V. Vora, BDS, MPH, Divya Persai, BDS, MPH, and Claudia Guerra, MSW, of the University of California, San Francisco, for contributing to data collection. We also thank Janelle Urata, RDH, MS, and Miranda Werts, BA, of the University of California, San Francisco, and David Cash, BA, of Stanford University for contributing to data collection and project management. These individuals made their contributions as part of their roles as paid employees of their institutions at the time of the study.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.