Global burden attributed to alcohol and drug use among adolescents and young adults, 1990–2019: results from the Global Burden of Disease Study 2019

Abstract

Objective

Adolescence is a critical period characterised by significant biological growth and transformative changes in social relationships. No authoritative study has provided a comprehensive analysis of the global burden attributed to alcohol and drug use among adolescents and young adults.

Study design, participants and methods

Data on alcohol and drug use among people aged 10–24 years were extracted from the Global Burden of Disease Study 2019. We reported the trends of death and disability-adjusted life years (DALYs) at the global, regional and national levels. We explored the sex and sociodemographic index distribution of disease burden.

Primary outcome measures

DALYs and deaths.

Results

In 2019, the number of deaths attributed to alcohol use and drug use among people aged 10–24 years was 59 855 and 16 391, respectively. The numbers of DALYs attributed to alcohol use and drug use were 5.9 million and 4.1 million, respectively. From 1990–2019, the global DALYs rate caused by alcohol use exhibited a downward trend for both males and females. The DALYs rate attributed to drug use in females among people aged 10–24 years exhibited a downward trend, while the DALYs rate attributed to drug use in males among people aged 10–24 years exhibited an upward trend. Furthermore, the burden attributed to alcohol use and drug use was significantly higher in males than in females. Eastern Europe had the highest burden attributed to alcohol use, and High-income North America had the highest burden of drug use.

Conclusions

Alcohol and drug use remain an important risk factor that poses substantial challenges to adolescent health, particularly among males. Countries must develop effective health policies and implement targeted regulatory measures.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• In addition to focusing on alcohol use disorders and drug use disorders, this study also highlights the broader health impacts of alcohol and drug use among adolescents and young adults.

• This study analysed the burden attributed to alcohol and drug use from multiple perspectives, including sex, age and socio-demographic index.

• However, our study considers only disability-adjusted life years and mortality, which may limit the interpretation of the findings.

• The data on alcohol use and drug use in the Global Burden of Disease study were partially obtained through self-reporting, which may be influenced by recall biases and social expectations.

Introduction

Adolescence is a critical period of both biological and psychological growth, as well as a crucial phase for the transformation of social relationships.¹ It is during this time that many individuals begin to develop habits related to alcohol and drug use, which can have significant long-term consequences.^{2 3} Recognised as a major contributor to the global burden of disease (GBD), alcohol carries substantial health risks and imposes substantial social and economic burdens when misused or consumed over an extended period.⁴ The detrimental effects of drug use on adolescents are rapid and severe. Research has consistently demonstrated strong associations between drug use and HIV prevalence, crime rates, self-harm and mental illness among adolescents.5,7 Therefore, gaining insight into the global burden of alcohol and drug use among adolescents and young adults is essential for effective policy planning and service organisation.

In America, alcohol and cannabis were the most commonly used substances among young adults, with usage rates reaching 81.4% and 40.1% respectively in 2019.⁸ Of particular concern is the increasing trend of drug use among adolescents following the legalisation of cannabis in America.^{9 10} Researchers from the UK, Canada, Argentina, Chile and other countries have conducted a series of similar cross-sectional studies among adolescents, which tended to have limited sample sizes and limited scope.11,13 The Global Burden of Disease Study has reported on the global burden and long-term trends of alcohol and drug use from 1990–2016,^{14 15} as well as population-level risks attributable to alcohol use by geography, sex and age from 1990–2020.¹⁶ Danpanichkul et al used data from GBD 2019 to demonstrate the significant global burden of alcohol and substance use disorders among adolescents and young adults, emphasising the urgent need to address this issue.¹⁷ However, no study has provided a detailed assessment of the global burden of alcohol and drug use among adolescents and young adults. In addition, the composition of disease burden attributable to alcohol and drug use among young people remains unclear, which limits the development of targeted public policies and effective health measures.

In this study, we retrieved data from the GBD 2019 to present the global, regional and national burden attributable to alcohol and drug use among adolescents and young adults aged 10–24 years. This study also elucidated differences in disease burden by sex, age and Socio-demographic Index (SDI) to inform targeted policies and effective health measures. Understanding these variations is critical to addressing the unique challenges faced by different demographic groups in terms of alcohol and drug use. Additionally, by analysing the composition of disease burden attributable to alcohol and drug use, we can gain insights into their impact on young people’s health.

Materials and methods

Study objects and definitions

GBD 2019 is a comprehensive study led by the Institute for Health Metrics and Evaluation, offering an extensive and systematic assessment of the disease burden attributable to 369 diseases, injuries, and 87 risk factors in 204 countries.^{18 19} Demographic information and disease burden estimates from GBD 2019 can be accessed through the global health data exchange query tool (https://gbd2019.healthdata.org/gbd-results/). We extracted epidemiological data on death and disability-adjusted life years (DALYs) from GBD 2019 to evaluate disease burden among adolescents. Adolescence is a critical period of biological and psychological growth, traditionally defined by the WHO as ages between 10–19 years. The GBD 2019 produced the 95% uncertainty intervals (UIs) for each indicator using the 25th and 975th estimates among 1000 random samples drawn from the posterior distribution. Considering the physical, psychological and behavioural characteristics of adolescents, we adopted an extended definition of adolescents and young adults aged 10–24 years.^{1 20} The effect of differences in the legality of adolescent alcohol and drug use varies across countries and is an important confounding factor. To mitigate the influence of various confounding factors, the GBD 2019 study adopted a comprehensive methodological framework, including standardised data collection, integrated assessment methods and weight adjustments.^{18 19} The Ethics Review Committee of Xiangya Second Hospital, Central South University, determined that ethical approval was not required for this study, as it used publicly available data that did not contain identifiable personal information.

In this study, we analysed the composition of health outcomes attributable to alcohol and drug use. In GBD 2019, diseases or injuries causally associated with alcohol use and drug use were categorised into four levels: level 1, level 2, level 3 and level 4. For these diseases and risk factors, the Bayesian meta-regression modelling tool (DisMod-MR 2.1) was used to generate estimated data.^{18 19} Drug use in the GBD 2019 included opioids, cocaine, amphetamines, cannabis and other drugs.¹⁸ Substance use disorders and health outcomes were defined according to the International Classification of Diseases 10th revision and Diagnostic and Statistical Manual of Mental Disorders 4th edition. We used mortality (an event-based measure) and DALYs (a time-based measure) to evaluate the disease burden. DALYs include years of life lived with disabilities (YLDs) and years of life lost due to premature death, combining them into a single metric that quantifies the total number of healthy years lost due to various causes.^{14 19} In GBD 2019, each country-specific, age-specific, sex-specific, and year-specific prevalence derived by DisMod-MR 2.1 was multiplied by a disorder-specific disability weight to estimate YLDs.¹⁹ The SDI is a composite indicator of social development, determined by education, income and fertility rate.²¹ The SDI ranges from 0–1, with higher values indicating higher socio-economic development levels of the corresponding country or region. In GBD 2019, countries and regions can be divided into five quartiles: high (>0.805), high-middle (0.690–0.805), middle (0.608–0.690), low-middle (0.455–0.608) and low (<0.455).

Statistical analysis

The numerical variables in this study were presented as means along with 95% UIs, and the rates were calculated per 100 000 population. We reported the total disease burden attributable to alcohol and drug use at global, regional and national levels by gender and SDI. In addition, we used Spearman rank correlation analysis to further investigate the associations between disease burden and SDI.²²

To analyse the temporal trend of burden attributed to alcohol and drug use among people aged 10–24 years from 1990–2019, we employed the Joinpoint Regression Program V.4.9.1.0 and calculated the average annual percent change (AAPC).^{20 22} The specific calculation method of AAPC can be found in the supplementary method. If the AAPC value and its lower boundary of 95% CI were both >0, an increasing trend of rates was deemed. In contrast, if the AAPC and its upper boundary of 95% CI were both <0, a decreasing trend of rates was deemed. All statistical analyses and data visualisations were conducted using the R program (V.4.3.0). The differences were considered significant when p<0.05, and the test level was set at α=0.05.

Results

Burden at the global level

In 2019, there were 59 855 deaths attributable to alcohol use and 16 391 deaths attributable to drug use among people aged 10–24 years (online supplemental table 1). From 1990–2019, the death rates attributed to alcohol use were also consistently higher than those attributable to drug use (figure 1). In 2019, the death rate attributable to alcohol use was 3.21 (2.63–3.85, per 100 000) globally, while the death rate attributable to drug use was 0.88 (0.8–0.99). Notably, from 1990–2019, the death rate attributed to alcohol use showed a downward trend with an AAPC of −0.94% (−1.13%–−0.76%). Conversely, the AAPC of death rate attributable to drug use was (−0.21% (−0.57%–0.16%)). (online supplemental table 1).

Figure 1. Global trends of death and disability-adjusted life years (DALYs) rates attributed to alcohol and drug use among people aged 10–24 years, 1990 to 2019. Global trends of death (A) and DALYs (B) rates attributed to alcohol and drug use for both sexes; Global trends of death (C) and DALYs (D) rates attributed to alcohol and drug use for males; Global trends of death (E) and DALYs (F) rates attributed to alcohol and drug use for females.

For young people aged 10–24 years, the global DALYs attributed to alcohol use were also significantly higher than those attributed to drug use. In 2019, there were 5.9 million DALYs attributable to alcohol use among people aged 10–24 years (online supplemental table 1). Meanwhile, the number of DALYs attributed to drug use was 4.1 million in 2019, about 69.5% of the DALYs attributed to alcohol use. In 2019, the DALYs rate attributable to alcohol use was 316.31 (260.21–380.65, per 100 000) globally, while the DALYs rate attributed to drug use was 217.8 (162.06–284.72). From 1990–2019, the global DALYs rate attributed to alcohol use also exhibited a downward trend (AAPCs: −0.86% (−1.07%–−0.65%)), while the DALYs rate attributable to drug use did not change significantly (AAPC: 0.01% (−0.19%–0.21%)) (online supplemental table 1).

Sex pattern of the burden

In terms of sex, the burden attributed to alcohol use and drug use was significantly higher in males compared with females (online supplemental table 1). In 2019, the DALYs rate attributed to alcohol use was 522.08 (431.01–624.35) in males, almost five times the rate in females (100.32 (78.08–129.35)). Meanwhile, the DALYs rate attributed to drug use was 259.49 (199.34–331.87) in males and 174.03 (121.57–238.77) in females, respectively. From 1990–2019, the death and DALYs rates attributed to alcohol use showed a downward trend in both males and females. More importantly, we observed that only the death rate and DALYs rate attributed to drug use in males among people aged 10–24 years exhibited an upward trend, with the AAPC of 0.4% (0.05–0.76%) and 0.13% (−0.01–0.27%) respectively (figure 1 and online supplemental table 1). Notably, the death rate due to drug use among females aged 10–24 was lower than that for alcohol use, while the DALY rate associated with drug use was higher than that for alcohol use.

Burden at the GBD regional level

The death rates and DALY rates attributed to alcohol use and drug use among people aged 10–24 years varied greatly among GBD regions (figure 2). In 2019, Eastern Europe had the highest death rate (11.5 (9.23–13.79)) and DALYs rate (954.91 (786.13–1132.75)) attributed to alcohol use (online supplemental tables 2 and 3). Notably, the death rate and DALYs rate attributed to drug use were significantly higher in High-income North America than any other GBD regions, up to four times the rates in Eastern Europe (the second highest). From 1990–2019, the DALYs rate attributed to alcohol use in 19 of 21 GBD regions showed a downward trend, with the fastest decline in Western Europe (AAPC: −1.71%; (−2.02–−1.4%)), followed by High-income North America and Australasia. However, 13 GBD regions showed an upward trend in the DALYs rate attributed to drug use, with the fastest rise in High-income North America (AAPC: 3.37%; (3.22–3.52%)). (online supplemental tables 2 and 3)

Figure 2. The death and disability-adjusted life years (DALYs) rates attributable to alcohol and drug use among people aged 10–24 years in 21 Global Burden of Disease (GBD) regions in 2019. The death (A) and DALYs (B) rates attributable to alcohol use in 21 GBD regions in 2019; The death (C) and DALYs (D) rates attributable to drug use in 21 GBD regions in 2019.

Burden at the national level

The death rates and DALYs rates attributed to alcohol use and drug use among people aged 10–24 years in 204 countries are shown in figure 3 and online supplemental figure 1. In 2019, the countries with the highest DALYs rate attributed to alcohol use were Ukraine (1227.68), Lesotho (1179.65), and Greenland (1114.07) (online supplemental table 4). Vietnam experienced the most significant increase in the DALYs rate attributed to alcohol use between 1990 and 2019, with an AAPC of 5.21% (4.95%–5.47%). In 2019, the countries with the highest drug-attributable DALYs rate were mainly developed countries, such as the USA (1853.42), Canada (1018.02) and Estonia (1010) (online supplemental table 5). Notably, over 80% of countries witnessed an increase in drug-attributable DALYs rates from 1990–2019, with Libya, the USA, and Sweden ranking at the top.

Figure 3. The disability-adjusted life years (DALYs) rate in 2019 and corresponding AAPCs attributed to alcohol and drug use among people aged 10–24 years in 204 countries and territories in 2019. The DALYs rate (A) and corresponding AAPCs (B) attributed to alcohol use; The DALYs rate (C) and corresponding AAPCs (D) attributed to drug use. AAPC, Average annual percentage changes.

Global trends by SDI

Online supplemental figure 2 shows the DALYs rate attributed to alcohol use and drug use among people aged 10–24 years in regions with different levels of SDI. In general, high-SDI regions had higher DALY rates attributed to alcohol use and drug use than low-SDI regions. Notably, the DALYs rate attributed to drug use in the high-SDI region showed a significant upward trend (AAPC: 2.85%; (2.74%–2.96%)) (online supplemental table 1). These findings suggest a certain correlation between the burden and socioeconomic development. Therefore, we further performed Spearman rank correlation analysis to verify this correlation. As shown in online supplemental figure 3, the results of Spearman rank correlation analysis confirmed that alcohol-attributable DALYs were weakly positively correlated with SDI (r=0.2032, p<0.01), while drug-attributable DALYs were strongly positively correlated with SDI (r=0.7374, p<0.0001).

Composition of disease burden

The composition of level 2 causes attributed to alcohol use and drug use among individuals aged 10–24 years varies across different regions (figure 4). Among adolescents and young people, alcohol use contributed to a broader spectrum of diseases and injuries compared with drug use (online supplemental table 6). Alcohol use disorders (AUDs), self-harm and interpersonal violence, and transport injuries were the top three level 2 causes contributing to alcohol use-attributable burden globally, accounting for the majority of the burden in high SDI and high-middle SDI regions (figure 4A). However, in low SDI regions, tuberculosis was also an important contributor to alcohol use-attributable burden. Compared with other consequences of drug use, drug use disorders emerged as the predominant level 2 cause of disease burden, accounting for 92.6% (figure 4B). In high SDI regions, self-harm was an important consequence of drug use, which should not be ignored.

Figure 4. The health composition of the burden attributed to alcohol and drug use among people aged 10–24 years in 2019. (A). The composition of health outcomes attributed to alcohol use in 2019; (B). The composition of health outcomes attributed to drug use in 2019. DALYs, disability-adjusted life years; SDI, sociodemographic index.

Discussion

This study provides a comprehensive analysis of the disease burden attributed to alcohol and drug use among adolescents and young adults aged 10–24 years. In 2019, there were 59 855 deaths attributed to alcohol use and 16 391 deaths attributed to drug use among adolescents and young adults. The corresponding DALYs were estimated at 5.9 million for alcohol use and 4.1 million for drug use. From 1990–2019, the death and DALYs rates attributed to alcohol use exhibited a significant downward trend among adolescents and young adults, despite population growth. This indicates notable progress in the long-term management of alcohol consumption among young individuals over the past few decades, primarily attributed to a range of regulatory policies implemented by governments, such as excise taxes, restrictions on alcohol advertising and controlling the availability of sales. However, considering the enduring consequences and substantial burden associated with alcohol use, it is imperative for the global health community to expedite efforts towards developing a framework convention on alcohol control similar to the existing WHO Framework Convention on Tobacco Control.¹⁴ Greater support needs to be given to policy responses to address alcohol in light of the enormous spending on drug intervention as compared with interventions aimed at addressing harms from alcohol use. Unfortunately, there has been no significant decrease observed in the global burden attributable to drug use; on the contrary, some high-SDI regions have witnessed a rapid upward trend. This may be influenced by varying levels of legality and patterns of drug use in these regions, making responses to these trends complex and challenging.

In 2019, alcohol and drug use were the primary risk factors for DALYs among individuals aged 10–24 years, accounting for 18.2% and 8.5% of DALYs, respectively. Regarding gender disparities, the burden attributed to alcohol use and drug use was significantly higher in males than in females among adolescents. Previous research has also indicated a greater burden of alcohol and drug use among middle-aged and elderly men compared with women.^{14 16} Our study suggests that this gender difference is already formed during adolescence. In addition, men and women showed different characteristics in their motivations for alcohol or drug use.²³ Men more often reported social reasons or pleasure, whereas women reported a desire to cope with stress, emotional problems and trauma.²⁴ These findings highlight the significance of tailored policies and interventions among young people, especially males. Notably, the death rate attributed to drug use among females aged 10–24 was lower than that for alcohol use, while the DALY rate associated with drug use was higher than that for alcohol use. This calls for greater attention to the non-fatal health effects of drug use in young women.

The deaths and DALYs attributable to alcohol use and drug use varied geographically, indicating a strong heterogeneity in the disease burden among adolescents worldwide. Our findings suggest that the disease burden attributed to alcohol and drug use among young people increased as SDI increased. In this study, Eastern Europe had the highest burden of alcohol use. The impact of culture, history and education on drinking patterns across Eastern Europe has been profound and enduring, leading to the highest levels of alcohol-related health damage.²⁵ The most notable result of this study was the significantly increased burden attributable to drug use in high-SDI regions, especially in High-income North America. High-SDI countries have higher levels of healthcare and economic development, along with considerably greater access to opioids or cannabis. From 2011–2013, high-income countries consumed over 95% of the world’s opioid analgesics, despite comprising only 15% of the global population.²⁶ In 2021, Europe and North America accounted for more than 80% of global morphine consumption.²⁷ Additionally, societal attitudes influenced by cultural and religious principles may contribute to the substantial burden of drug use among adolescents.^{26 28}

The composition of disease burden attributable to alcohol use and drug use also varied widely among adolescents. Among individuals aged 25 and above, digestive diseases, AUDs, and neoplasms emerged as the primary contributors to the global burden of alcohol use.¹⁶ However, apart from AUDs, our study indicates that self-harm, interpersonal violence, and transport injuries significantly contributed to the alcohol-related burden among individuals aged 10–24 years. Self-harm and violent injury among adolescents have long been a social concern, and alcohol use can increase the likelihood of such incidents.^{29 30} Both the government and society should make efforts and develop comprehensive measures to reduce alcohol-related violence or traffic injuries, such as introducing mental health education programmes and imposing restrictions on nocturnal alcohol sales to adolescents. Compared with other consequences, drug use disorders emerged as the predominant cause of disease burden. In addition, the proportion of burden attributable to drug use disorders was higher in people aged 10–24 years than in people aged 25 and above (92.6% vs 53.4%).³¹ Opioids are commonly prescribed analgesics frequently used for managing postoperative and cancer-related pain. In this study, opioid use disorders also accounted for the highest proportion among drug use disorders. Adolescents engaging in the misuse of prescription opioids primarily acquire these drugs through a single prescriber or social network, often involving relatives or friends.³² Therefore, it is imperative for governments to establish available intervention strategies aimed at enhancing the management of opioids. Associations have been found between adolescents who engage in drug use and mental health disorders.⁹ In high SDI regions, self-harm has been observed to be associated with drug use, which should be of concern. Adolescents with drug misuse exhibited a 1.77-fold increased risk of single suicide attempt and a 3.23-fold increased risk of multiple suicide attempts, compared with those without drug misuse.³³

To the best of our knowledge, this study represents the first comprehensive analysis of the global burden attributed to alcohol and drug use among adolescents and young adults aged 10–24 years. In addition to focusing on AUDs and drug use disorders, our research also highlights the broader health impacts of alcohol and drug use in this population.¹⁷ It will serve as a significant reference for government agencies and healthcare professionals. Moreover, this study employs a standardised model evaluation approach to derive a range of data estimates for burden, enabling cross-location and longitudinal comparisons. However, our study still has several limitations. First, this study is questioned by some common shortcomings like other GBD studies, such as variations in data sources and quality, particularly in undeveloped regions. Furthermore, the data on alcohol use and drug use in the GBD study were partially obtained through self-reporting, which may be influenced by recall biases and social expectations.¹⁶ Lastly, GBD 2019 did not properly account for the burden of alcohol use on the incidence and progression of HIV/AIDS.³⁴ Lastly, this study did not look at particular drugs or classes of drugs, and it also did not compare adolescents with young adults, which would be important directions for future research.

Conclusion

In conclusion, our study indicates that alcohol use and drug use remain important risk factors that pose substantial challenges to adolescent health, particularly among males. Overall, the burden attributed to alcohol and drug use was higher in high-SDI and high-middle-SDI regions, with Eastern Europe having the highest burden of alcohol use and High-income North America having the highest burden of drug use. Considering the enduring consequences of alcohol and drug use, countries must develop effective health policies and implement targeted regulatory measures.

Data availability statement

Data are available in a public, open access repository.