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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: Psychol Addict Behav. 2021 Jun 7;35(6):671–681. doi: 10.1037/adb0000756

Traditional Risk and Cultural Protection: Correlates of Alcohol and Cannabis Co-Use among African American Adolescents

Devin E Banks a,*, Tennisha N Riley b, Donte L Bernard c, Sycarah Fisher d, Jessica Barnes-Najor e
PMCID: PMC8487906  NIHMSID: NIHMS1703321  PMID: 34096747

Abstract

Objective:

Previous work indicates that African American adolescents are at high risk for concurrent alcohol and cannabis use. The current study examines the associations of traditional ecological predictors of substance use with concurrent alcohol and cannabis use among African American adolescents. It also examines whether racial identity, a culturally-relevant factor, is associated with concurrent use beyond the influence of traditional factors.

Methods:

Secondary analyses were conducted based on a large survey of high school adolescents. Responses on self-report measures of substance use and psychosocial determinants of health were examined for those respondents in grades 9–12 who identified as African American (N = 465; 59.8% female).

Results:

Findings demonstrated that traditional risk and resilience factors, including externalizing symptoms and substance use beliefs, were related to alcohol and cannabis co-use relative to other patterns of use among African American adolescents. Racial identity dimensions were also associated with alcohol and cannabis co-use beyond the influence of traditional factors. However, the direction of these associations varied by dimension.

Conclusions:

Findings from the present study assist in advancing the current knowledge base by identifying potential risk and protective factors for alcohol and cannabis co-use among African American youth, who face increasing rates of this substance use pattern. They also underscore the importance of accounting for cultural variability in models of adolescent substance use among this population.

Keywords: African American, adolescent, substance use, cannabis, racial identity

Alcohol and cannabis are the two most commonly used substances among adolescents in the United States (Miech, Johnston, et al., 2019). Most attempts to understand mechanisms of alcohol and cannabis behaviors have focused on each substance individually although 35–44% of adolescents who currently use alcohol (i.e., in the past month) also use cannabis while more than half of those who use currently use cannabis also use alcohol (Banks et al., 2017; Patrick et al., 2018). Rates of concurrent alcohol and cannabis use have increased disproportionately among African American adolescents (Lanza et al., 2015) despite evidence that they are less likely to engage in concurrent substance use than their White peers (Tomczyk et al., 2016). Indeed, recent data have demonstrated that African American adolescents are at high risk for concurrent alcohol and cannabis use relative to other single and concurrent substance use patterns (Banks et al., 2020; Banks et al., 2017). This is concerning because concurrent alcohol and cannabis use is associated with greater substance-related consequences relative to single substance use, including greater alcohol and cannabis consumption, increased social, academic, and legal consequences, and higher rates of comorbid substance use and mental health disorders (Green et al., 2016; Karoly et al., 2020; Yurasek et al., 2017). As African Americans face greater physical, social, and psychological costs of substance use relative to their White counterparts (Chartier & Caetano, 2010; Zapolski et al., 2014)—including higher rates of concurrent substance use disorders (McCabe et al., 2017; Pacek et al., 2012)—identifying factors that influence concurrent alcohol and cannabis use during adolescence may help disrupt the development of racial disparities during adulthood.

Theoretical models explaining concurrent alcohol and cannabis use include the gateway hypothesis (Kandel, 1975; Kandel & Kandel, 2015) and the common liability model (Conway et al., 2010; Palmer et al., 2012; Vanyukov et al., 2003). The gateway hypothesis posits a progressive stage model of substance use whereby adolescents initiate licit drugs such as alcohol before progressing to illicit drugs such as cannabis. Although the most common sequences of adolescent substance use provide continued support for the gateway hypothesis (Kandel & Kandel, 2015), African American adolescents are more likely than their White peers to deviate from the gateway sequence and initiate cannabis before alcohol, limiting the application of this model to Black adolescents (Fairman et al., 2019; White et al., 2007). Alternatively, the common liability model posits that a specific set of biological and psychosocial mechanisms comprise a latent dimension that underlies a general liability to both alcohol and cannabis. This model overlaps with those that have identified mechanisms of alcohol use or cannabis individually as well as those concerning general adolescent substance use (Vanyukov, et al., 2012). Both the gateway hypothesis and common liability model suggest common underlying mechanisms contribute to the development of both alcohol and cannabis use. Because of this, the models have recently been described as complementary (Kandel & Kandel, 2015; Keyes et al., 2019; Mayet et al., 2016) and research examining mechanisms of concurrent alcohol and cannabis use have turned to prominent theoretical models of general substance use as a foundation for identifying such mechanisms.

Besides biological mechanisms, models of adolescent substance use have implicated individual and psychological factors (e.g., substance related attitudes, psychological distress, and other problem behaviors) as well as social learning, attachment, and social support processes (e.g., peer and parent influences) in the development of adolescent substance use (Petraitis et al., 1995). More recently, models have also emphasized the influence of community and structural factors (e.g., neighborhood environment and school characteristics) on adolescent substance use (Allison et al., 1999; Chassin et al., 2009; Hawkins et al., 1992) leading to a social ecological perspective toward single (Ennett et al., 2008) and concurrent adolescent substance use (Bronfenbrenner, 1994; Connell et al., 2010).

However, traditional social ecological models of substance use (i.e., those that incorporate individual, social, and community factors thought to generalize across racial groups) have had difficulty accounting for variance in substance use among African American adolescents relative to their White peers (Bersamin et al., 2005; Brown et al., 2004; Wallace & Muroff, 2002; White et al., 2007). Researchers have theorized that traditional models are insufficient for African American youth because they do not consider that the United States’ racialized social system leads to process differences (e.g., differences in the impact of factors) and compositional differences (e.g., differences in exposure to factors) in the development of substance use among this group (Wallace, 1998; Watt, 2008). Thus, the addition of culturally-relevant, race-related factors may account for compositional differences and improve models of substance use for African American adolescents. Indeed, race-related factors such as racial discrimination and racial identity have been found to explain substance use above and beyond the influence of traditional ecological factors (Fisher et al., 2019; Stock et al., 2013; Zapolski et al., 2020), improving the predictive utility of ecological models among this group.

The current study extends this approach to improve understanding of concurrent alcohol and cannabis co-use among African American adolescents. We first examine associations between traditional ecological factors at all three levels (individual, social, and community) and concurrent alcohol and cannabis use. We then examine whether racial identity, a race-related psychological factor typically associated with adaptive health behavior (Rivas-Drake, Seaton, et al., 2014), is associated with concurrent alcohol and cannabis above and beyond the influence of traditional ecological factors. Concurrent alcohol and cannabis in the current study is defined as the use of both substances in the past 30 days, but not necessarily on the same occasion (i.e., simultaneously).

Traditional Correlates of Concurrent Alcohol and Cannabis Use

Among studies characterizing common substance use patterns, traditional ecological mechanisms of single substance use are also associated with concurrent substance use. Two recent reviews revealed that adolescents with greater internalizing and externalizing symptoms, peer and parent substance use, and lower academic achievement or school engagement are consistently more likely to engage in concurrent use patterns. However, these reviews revealed that studies to date have been limited by 1) examining primarily White youth, limiting their generalizability to African American youth and 2) the tendency to compare concurrent use patterns to non-use, limiting understanding of differences between adolescents who engage in single versus concurrent use patterns (Halladay et al., 2020; Tomczyk et al., 2016).

There is some evidence that traditional mechanisms of general substance use also differentiate concurrent alcohol and cannabis use from single substance use. Concurrent alcohol and cannabis use has been positively associated with individual factors such as internalizing symptoms (Conway et al., 2013), externalizing symptoms, and permissive substance use beliefs (Silveira et al., 2019; Su et al., 2018), social factors such as lack of parental involvement and peer substance use (Su et al., 2018), and community factors such as low school engagement (Patrick et al., 2018). However, all of these studies examined concurrent alcohol and cannabis use relative to single alcohol or cannabis use the past year. Among African American adolescents specifically, high externalizing symptoms and low parental involvement have been linked to greater odds of concurrent alcohol and cannabis use relative to alcohol only use, although these studies were based on measures of lifetime and past year substance use (Chung et al., 2013; Johnson et al., 2020). Thus, although this research has helped shape our understanding of the factors underlying concurrent alcohol and cannabis co-use among adolescents in general, little work has examined current use (i.e., within the past-30-days) or African American adolescents.

Cultural Correlates of Substance Use among African Americans

Recent reviews of the literature implicate racial identity as an important cultural (in this case, race-related) factor that confers resilience against behavioral health problems, including the development of substance use behavior, among racial minority adolescents (Rivas-Drake, Seaton, et al., 2014; Rivas-Drake, Syed, et al., 2014). Racial identity, a social identity or self-concept relating to the meaning, belongingness, and significance one ascribes to their race (Phinney, 1992; Sellers et al., 1998), is thought to reduce the likelihood of substance use via socialization towards cultural norms that are less permissive of substance use (Unger, 2011; Zapolski et al., 2020). Racial identity has been conceptualized as a developmental process that involves three components: gaining clarity and resolution about the meaning of one’s race, affect and regard toward one’s race, and behavioral engagement with one’s race (Sellers et al., 1998).

Among African American youth specifically, several aspects of racial identity confer resilience against substance use. Public regard, which concerns how adolescents feel others view their racial group, and identity exploration, which refers to behavioral engagement with one’s racial group, are both inversely associated with alcohol and cannabis co-use among African American adolescents (Nasim et al., 2007; Stock et al., 2013; Zapolski et al., 2019; Zapolski et al., 2016). The strongest evidence of the link between racial identity and substance use has concerned private regard (Rivas-Drake, Seaton, et al., 2014)—the magnitude of pride, affirmation, and belonging towards one’s race—which is associated with substance use beyond other facets of racial identity (Zapolski et al., 2019) and predicts substance use behavior over time among African American adolescents (Stock et al., 2013).

Although racial identity has been identified as an important factor in substance use behavior of African American adolescents, it has not been examined in relation to different patterns of substance use among this group. One recent study among African American young adults found that positive private regard was inversely associated with cannabis and alcohol co-use, but not alcohol only use, relative to non-use (Banks et al., 2021). This points to the importance of considering the impact of racial identity not only in the development of single substance use, but also in the development of concurrent substance use among African American youth.

Current Study

Despite disproportionate increases in cannabis use and alcohol and cannabis co-use among African American adolescents, this group has been largely overlooked among emerging research seeking to understand adolescent co-use. The current study examines whether traditional ecological correlates previously associated with alcohol and cannabis co-use among predominantly White samples are also associated with this pattern of use among African American adolescents. Based on extant research summarized previously, these include individual factors including permissive substance use beliefs and internalizing and externalizing symptoms, social factors including low parental involvement and low peer support, and community factors including low school and neighborhood engagement. We also examine the additive contribution of racial identity to the differentiation of alcohol and cannabis use patterns. We hypothesize that racial identity facets (private regard, public regard, and exploration) will be inversely associated with alcohol and cannabis co-use beyond the influence of traditional factors. As much of the previous literature on this topic have examined factors that distinguish concurrent use from non-use, we examine these traditional and cultural factors that distinguish concurrent use from non-use and single substance use patterns (i.e., alcohol only and cannabis only use).

Methods

Participants and Procedures

The current study includes secondary analysis of a 5-year (2005–2010) survey assessing student outcomes among a diverse sample of youth in a large Midwestern county. Each year of recruitment included youth in grades 4 through 12 drawn from 159 elementary, middle, and high schools that elected to participate. Informed consent forms were sent home to parents of all students, and interested parents were asked to return signed forms back to the school to provide consent. This same procedure occurred each year in all schools as the study was not designed to be longitudinal, but rather to assess annual health behaviors of students in the region. Students completed a 208-item questionnaire regarding physical, social, and psychological well-being using multi-item scales selected by educators, researchers, and community members from public and peer-reviewed sources such as the MI 21st Century Statewide Evaluation, CA Health Kids Survey, the Centers for Disease Control and Prevention’s YRBS survey, and the SEARCH Institute’s 40 Developmental Assets for Adolescents instrument (see Barnes et al., 2009, for further information about the parent study). The current study examined African American high school students in grades 9 through 12 who responded at year 5, which was not only the most recent survey but also had the highest response rate from non-Hispanic African American high-school aged youth. In that year, 2745 high-school aged respondents completed the survey, 510 (19%) of which identified as African American, which corresponded with the proportion of African American residents in the region in 2010 (approximately 20%).

Measures

Substance Use

Participants were asked to indicate their engagement in substance use related behaviors over the past 30 days. Participants indicated the number of days they: “smoked cigarettes,” “had at least one drink of alcohol,” and “used marijuana.” Each substance was coded dichotomously (yes/no) to represent past-30-day use. Based on their responses to the alcohol and cannabis questions, participants were coded to non-use, alcohol only use, cannabis only use, and alcohol and cannabis co-use (reference category).

Traditional Factors

As discussed previously, traditional ecological factors thought to differentiate substance use patterns included substance use beliefs, externalizing and internalizing symptoms, peer support, parent involvement, school engagement, and neighborhood engagement. For substance use beliefs, participants were asked how harmful they thought it was to “drink alcohol occasionally” and “use marijuana” on a 3-point scale ranging from 1 (very bad for you) to 3 (not very bad for you). Higher scores indicate more permissive alcohol- and cannabis-related beliefs, respectively.

Externalizing symptoms were assessed with four items measuring the frequency of disruptive behaviors (“I lied to my parents about something important,” “I took something on purpose that was not mine,” “I did something my parents told me not to do,” “I got arrested or picked up by the police”). Participants were asked to rate how often they had engaged in each behavior during the past year on a scale ranging from 1 (never) to 4 [regularly (every week or two)]. Responses were averaged for a total scale with higher scores indicating more externalizing behavior (alpha = .72). Internalizing symptoms during the past year were assessed using a 13-item version of the Center for Epidemiologic Studies Depression Scale (Radloff, 1977). For some of the items we used the exact wording, and for others we changed the questions to improve understanding for young, culturally-diverse children (e.g., when the original question was “My sleep was restless” we changed the wording to “I had a hard time sleeping”). Responses were averaged to generate a scale with higher scores indicative of more internalizing symptoms (alpha = .89).

Peer support was measured with five items (e.g., “My friends help me when I am having a hard time”) rated on a four-point scale from 1 (strongly disagree) to 4 (strongly agree). Responses were averaged for a total scale with higher scores indicating more peer support (alpha = .92). To assess parental involvement, respondents were asked how often their “parents or caregiver (whoever takes care of you)” engaged in nine behaviors indicating involvement (e.g., “talk to you about your problems,” “check whether you have done your homework”). Responses ranged from 1 (never) to 4 (a lot). Responses were averaged to generate a scale with higher scores indicative of more parental involvement (alpha = .79).

School engagement was assessed using a measure comprising three subscales, which assessed respondents’ behavioral, cognitive, and emotional commitment to schooling, respectively (Arsenault et al., 2018). Respondents were asked to rate their behavioral engagement (e.g., “I always write down my homework assignments”) on a scale ranging from 1 (Not at all like me) to 4 (A lot like me). They rated both their cognitive engagement (e.g., “I believe schoolwork is very important”) and emotional engagement (“I enjoy learning new things at my school”) on a scale ranging from 1 (strongly disagree) to 4 (strongly agree). Responses were averaged for a total score, with higher scores indicating greater school engagement (alpha = .87). Neighborhood engagement was assessed with six items (e.g., “I like my neighborhood,” “I actively participate in my neighborhood’s activities”) rated on a scale from 1 (strongly disagree) to 4 (strongly agree). Responses were averaged to generate a scale with higher scores indicative of greater neighborhood engagement (alpha = .88)

Cultural Factors

The multi-group Ethnic Identity Measure (MEIM) (Phinney, 1992) was used to measure racial identity exploration and racial identity affirmation, or private regard. The MEIM prompts respondents to write in their “ethnic group” and subsequently, includes 12 items regarding that ethnic group identity. Participants in the current sample either indicated they were “Black,” “African American,” or “Black/African American.” Of the 12 MEIM items, six measure exploration (e.g., “In order to learn more about my ethnic background, I have often talked to other people about my ethnic group”) and six measure private regard (e.g., “I feel good about my cultural or ethnic background”). Although developed to demonstrate ethnic identity across groups, the MEIM scales have been shown to closely relate to racial identity among African Americans (Casey-Cannon et al., 2011; Worrell & Gardner-Kitt, 2006), and have been reliably used as a measure of racial identity in previous studies examining substance use among this group (Stock et al., 2013). Items were rated on a 4-point Likert scale, with responses ranging from 1 (strongly disagree) to 4 (strongly agree). Responses were averaged for each scale so that higher scores represent greater exploration and affirmation/private regard, respectively (alpha = .79 and .89, respectively). Public regard was measured using the public subscale of the Collective Self Esteem Scale - Race (Crocker et al., 1994; Cross, 1991), which assesses the extent to which one believes their racial group is valued by others (e.g., “Overall, my racial/ethnic group is considered good by others”). Participants responded to the four items of the public collective self-esteem subscale on a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). Higher scores are indicative of beliefs that others view one’s race more positively. Reliability for the scale within the current study (α = .65), was consistent with previous estimates (Constantine et al., 2002; Wallace & Fisher, 2007).

Data Analysis

All analyses were performed using SPSS 25.0. Preliminary analyses included examining zero-order correlations among the variables of interest and between demographic variables (i.e., grade and sex) and alcohol and cannabis co-use. Alcohol and cannabis use patterns were computed using past-30-day substance use such that respondents were included in four mutually exclusive categories: no use, alcohol only use, cannabis only use, and alcohol and cannabis co-use. Multinomial logistic regression was used to estimate category membership from traditional and cultural factors with alcohol and cannabis co-use serving as the reference category. A hierarchical framework was used whereby traditional factors were entered into the first step and cultural factors were entered into the second step. McFadden pseudo-R2 statistics were used to compare models. Covariates in all models included grade and sex given consistent grade and sex differences in substance use behaviors documented in national surveys of adolescents (Miech, Johnston, et al., 2019). Models also included cigarette use as a covariate because rates of cigarette use among African American youth have been found to help account for increasing rates of cannabis use among this group (Miech, Terry-McElrath, et al., 2019).

Results

Of the 510 African American respondents, 45 were missing data on at least one of the variables; 35 of these cases (7% of respondents) were missing substance use data. The final analytic sample (N = 465) included African American respondents in grades 9 through 12 (Median = 10). The sample was over half female (59.8%) with an average age of 15.6 (SD = 1.2). With regard to substance use, 21.7% of the sample reported past-30-day alcohol use and 17.5% reported cannabis use (relative to rates of 19% and 17%, respectively, among nationally-representative surveys of adolescents) (Miech, Johnston, et al., 2019). Alcohol and cannabis use were significantly related (x2 = 85.68, p < .001, V = .42); 48.1% of respondents who used alcohol in the past 30 days also used cannabis, whereas 59.5% who used cannabis also used alcohol. With regard to patterns of single and co-use, most of the sample reported no use in the past 30 days (71.3%), followed by alcohol only use (11.4%), alcohol and cannabis co-use (10.6%), and cannabis only use (6.7%).

Zero-order correlations are presented in Table 1 and descriptive statistics by substance use pattern are presented in Table 2. There were no differences in substance use pattern by sex but significant differences were observed by grade (F = 3.27, p = .021) such that adolescents in higher grades were more likely to engage in alcohol and cannabis co-use than alcohol only use (d = .58). Cigarette use was associated with greater likelihood of alcohol and cannabis co-use relative to alcohol only- and non-use. Several traditional factors, including more permissive alcohol use beliefs, greater externalizing symptoms, and less school engagement were associated with the alcohol and cannabis co-use category although associations varied relative to other patterns of use (see Table 2). With regard to cultural factors, identity exploration and private regard were highly correlated (r = .58), raising concerns about multicollinearity in regression analyses (Donath et al,. 2012; Vatcheva et al., 2016). Although collinearity values were acceptable (VIFs = 1.76), when evaluated relative to model fit (R2 = .21) as recommended by Freund and colleagues (2006), VIF for each dimension of racial identity were larger than the equation 1/(1 - model R2), indicating that their correlation was stronger than the regression relationship and multicollinearity may affect coefficient estimates. Thus, in subsequent analyses, identity exploration and private regard were examined in separate models.

Table 1.

Zero-order correlations for study variables

1 2 3 4 5 6 7 8 9 10 11 12 13 14
1. Grade -
2. Sex (female) −.02 -
3. Cigarette use .00 .08 -
4. Alcohol beliefs .17 .04 .14 -
5. Cannabis beliefs −.03 .02 .19 .28 -
6. Internalizing symptoms .04 .18 .12 .11 .21 -
7. Externalizing symptoms −.03 −.13 .26 .25 .16 .25 -
8. Peer support .09 .23 −.16 −.01 −.03 −.10 −.12 -
9. Parental involvement −.14 −.05 .00 −.21 −.05 −.20 −.17 .13 -
10. School engagement .09 .20 −.19 −.07 −.10 −.14 −.37 .32 .31 -
11. Neighborhood engagement −.05 −.09 −.01 −.16 .00 −.15 −.16 .17 .39 .21 -
12. Public regard −.16 .00 −.05 −.14 −.03 −.16 −.07 .14 .09 .13 .06 -
13. Private regard .12 .07 −.05 .08 −.05 −.12 −.10 .24 .06 .36 .07 .11 -
14. Exploration .05 .04 −.04 −.03 .07 −.01 −.11 .19 .25 .34 .25 .01 .58 -
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Note. Bold values indicate significant values at p < .05.

Table 2.

Descriptive statistics of study variables by substance use category

Alcohol & Cannabis Co-Use
49 (10.5%)		 Cannabis Only
31 (6.7%)		 Alcohol Only
53 (11.4%)		 Non-Use
332 (71.4%)		 Total
465 (100.0%)
M (SD) or n (%)
Covariates
Grade 10.35 (1.07)a 10.06 (1.15)ab 9.74 (1.00)b 9.89 (1.01)b 9.93 (1.03)
Sex (female) 30 (61.2%) 15 (48.4%) 33(62.3%) 200 (60.2%) 278 (59.8%)
Cigarette use 14 (28.6%)a 4 (12.9%)ab 2 (3.8%)bc 3 (0.9%)c 23 (4.9%)
Traditional Factors
Alcohol beliefs 2.08 (.76)a 1.68 (.70)bc 1.96 (.65)ab 1.44 (.65)c 1.58 (.71)
Cannabis beliefs 1.37 (.67)a 1.10 (.40)b 1.15 (.46)ab 1.11 (.38)b 1.14 (.43)
Internalizing symptoms 2.25 (.66) 2.02 (.65) 2.12 (.56) 2.01 (.60) 2.05 (.62)
Externalizing symptoms 2.11 (.78)a 1.67 (.50)b 1.62 (.45)b 1.47 (.43)b 1.58 (.53)
Peer support 3.21 (.82) 3.30 (.49) 3.16 (.73) 3.36 (.64) 3.30 (.66)
Parental involvement 2.31 (.61) 2.52 (.51) 2.33 (.61) 2.52 (.62) 2.48 (.62)
School engagement 3.10 (.44)a 3.14 (.45)ab 3.19 (.35)ab 3.30 (.34)b 3.24 (.39)
Neighborhood engagement 2.33 (.91) 2.43 (.66) 2.11 (.61) 2.38 (.74) 2.36 (.76)
Cultural Factors
Public regard 2.82 (.58)ab 3.04 (.54)a 2.59 (.54)b 2.79 (.68)ab 2.79 (.66)
Private regard 2.98 (.71) 3.12 (.64) 3.17 (.72) 3.16 (.64) 3.13 (.66)
Exploration 2.38 (.74) 2.34 (.77) 2.64 (.72) 2.62 (.66) 2.59 (.69)
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Note: Groups sharing the same superscript or no superscript are not significantly different at p < .05 based on Tukey-Kramer or chi-square tests.

Traditional Factors and Alcohol and Cannabis Co-Use

The pattern of results of the multinomial regression analyses including traditional factors were similar in models adjusted and unadjusted for demographic covariates; the adjusted model is reported to demonstrate demographic differences in alcohol and cannabis use patterns. The model including covariates and traditional factors was significant (x2 = 157.18, p < .001, pseudo-R2 = .187). Regarding covariates, higher grade and cigarette use were associated with lesser odds of alcohol only use and non-use relative to alcohol and cannabis co-use; no covariates distinguished cannabis only use from alcohol and cannabis co-use (see Table 3). Regarding traditional factors, more permissive alcohol beliefs (OR = .40, 95% CI: .24–.68, p < .001) and greater externalizing symptoms were associated with lower odds of non-use relative to alcohol and cannabis co-use (OR = .18, 95% CI: .09–.36, p < .001). Greater externalizing symptoms were also associated with lower odds of alcohol only use relative to alcohol and cannabis co-use (OR = .21, 95% CI: .09–.49, p < .001). Neighborhood engagement was also associated with lower odds of alcohol only use relative to alcohol and cannabis co-use (OR = .48, 95% CI: .25–.94, p = .032). Finally, externalizing symptoms were associated with lower odds of cannabis only use relative to alcohol and cannabis co-use (OR = .31, 95% CI: .12–.82, p = .018).

Table 3.

Results of multinomial regression estimating alcohol & cannabis co-use from traditional and cultural factors

Cannabis Only Alcohol Only Non-Use
B SE x 2 OR 95% CI p B SE x 2 OR 95% CI p B SE x 2 OR 95% CI p
Covariates
Grade −.35 .25 1.90 .71 .43–1.16 .168 −.94 .24 14.90 .39 .24–.63 <.001 −.64 .19 10.77 .53 .36–.77 .001
Sex (male) .82 .57 2.09 2.26 .75–6.86 .148 .55 .53 1.10 1.74 .62–4.90 .295 .77 .44 3.00 2.15 .09–5.13 .083
Cigarette use −.75 .73 1.04 .47 .11–1.99 .309 −2.48 .95 6.81 .08 .01–.54 .009 −3.43 .79 18.82 .03 .01–.15 <.001
Traditional Factors
Alcohol beliefs −.38 .35 1.17 .68 .34–1.36 .279 .19 .34 .33 1.21 .63–2.35 .568 −.98 .28 12.60 .38 .22–.65 <.001
Cannabis beliefs −.66 .60 1.20 .52 .16–1.68 .274 −.75 .45 2.83 .47 .20–1.13 .092 −.36 .36 1.03 .70 .35–1.40 .311
Internalizing symptoms .14 .44 .10 1.15 .49–2.73 .857 .06 .41 .02 1.06 .48–2.38 .879 .02 .34 .01 1.03 .53–1.99 .943
Externalizing symptoms −1.17 .48 5.91 .31 .12–.80 .015 −1.67 .47 12.46 .19 .08–.48 <.001 −1.71 .37 21.49 .188 .09–.37 <.001
Peer support .17 .41 .16 1.18 .53–2.65 .687 −.19 .37 .27 .82 .40–1.72 .604 .20 .32 .40 1.22 .66–2.28 .526
Parental involvement .50 .49 1.04 1.64 .63–4.26 .309 .05 .44 .01 1.05 .44–2.51 .909 .13 .37 .13 1.14 .56–2.33 .723
School engagement −.47 .72 .43 .63 .15–2.56 .515 −.14 .73 .04 .87 .21–3.64 .850 .59 .59 .99 1.79 .57–5.68 .320
Neighborhood engagement −.15 .37 .16 .86 .41–1.79 .686 −.88 .36 5.91 .42 .21–.84 .015 −.57 .29 3.83 .57 .32–1.00 .050
Cultural Factors
Public regard .14 .42 .12 1.15 .51–2.61 .735 −.98 .38 6.72 .38 .18–.79 .010 −.64 .32 3.98 .53 .28–.99 .046
Private regard .47 .50 .87 1.60 .60–4.29 .351 .07 .46 .02 1.07 .43–2.65 .881 .21 .38 .31 1.24 .59–2.60 .575
Exploration −.33 .45 .56 .72 .30–1.72 .456 .82 .43 3.56 2.26 .97–5.29 .059 .35 .34 1.01 1.41 .72–2.77 .315
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Note. Bold values indicate significant values at p < .05. Substance use categories are relative to reference group: alcohol and cannabis co-use.

Racial Identity and Alcohol and Cannabis Co-Use

Results of the multinomial regression including all covariates, traditional, and cultural variables are reported in Table 3. When racial identity domains were added to the traditional model, the model was significant and improved (x2 = 179.99, p < .001, pseudo-R2 = .214). Traditional factors remained associated with alcohol and cannabis co-use in the same pattern as in the previous model (see Table 3) and racial identity dimensions were associated with alcohol and cannabis use beyond the impacts of traditional factors in the models both unadjusted and adjusted for demographic covariates. In the adjusted model, a one unit increase in public regard was associated with 47% lesser odds of non-use and 62% lesser odds of alcohol only use relative to alcohol and cannabis co-use. Public regard did not differentiate alcohol and cannabis co-use from cannabis only use.

Private regard and exploration were not significantly associated with alcohol and cannabis co-use in the full multivariate model but were also explored separately after adjusting for public regard due to their expected multicollinearity. In the model without private regard, identity exploration was associated with a more than two-fold increase in the odds of alcohol only use relative to alcohol and cannabis co-use (OR = 2.34, 95% CI: 1.14–4.79, p = .021). Private regard did not differentiate alcohol and cannabis co-use from non-use (OR = 1.57, 95% CI: .89–2.77, p = .117) or cannabis only use (OR = .91, 95% CI: .44–1.87, p = .796). In the model without identity exploration, private regard was unrelated to substance use pattern as in the multivariate model.

Discussion

The current study identified correlates of concurrent alcohol and cannabis use among African American adolescents based on traditional ecological and cultural predictors of adolescent substance use. The first aim of the study sought to identify the association between traditional predictors of substance use and concurrent alcohol and cannabis use. Consistent with previous research among general (Silveira et al., 2019; Su et al., 2018) and African American samples (Chung et al., 2013; Johnson et al., 2020), permissive substance use beliefs and externalizing behavior were associated with concurrent alcohol and cannabis use. Specifically, permissive alcohol beliefs differentiated non-use from alcohol and cannabis co-use but cannabis beliefs were not differentially associated with substance use pattern. Previous research has demonstrated that alcohol use beliefs but not externalizing symptoms predict concurrent alcohol and cannabis use among White adolescents whereas externalizing symptoms but not alcohol use beliefs predict this pattern among African American adolescents (Chung et al., 2013). Taken with the current results, these findings suggest that substance-related cognitions are important in the initial development of substance use behaviors among African American youth (e.g., Zapolski et al., 2016) but not in the development of the underlying severity that manifests as a common liability for alcohol and cannabis use (Vanyukov et al., 2012). This may be due to the reciprocal relationship between substance use beliefs and substance use (Gerrard et al., 1996). Perhaps because adolescents who use substances tend to have more permissive beliefs about them, permissive beliefs do not vary significantly among adolescents who use regardless of their pattern of use.

Externalizing behavior was the only factor that differentiated co-use from all other substance use patterns and was the only traditional factor that differentiated co-use from cannabis only use. The link between externalizing symptoms and adolescent substance use is well-established but research examining whether externalizing symptoms differentiate between patterns of substance use is nascent. The current findings support previous evidence that externalizing symptoms are not only associated with initiation and magnitude of substance use, but also associated with a developmental progression to patterns of use characterized by multiple substances (Collins et al., 2000; King et al., 2004). This finding supports the common liability model, which suggests that propensity to both alcohol and cannabis use share underlying mechanisms that may manifest as behavioral antecedents, particularly problem behaviors (Jessor & Jessor, 1977; Vanyukov et al., 2012). Although externalizing behavior is associated with substance use in general, severe externalizing behavior may be an indicator for more severe patterns of substance use.

The second aim of the study was to examine the unique association of three race-related correlates of substance use—identity exploration, private regard, and public regard—with alcohol and cannabis co-use beyond the contributions of traditional factors. Results illustrated that a complex relationship exists between racial identity and concurrent alcohol and cannabis use after accounting for traditional factors. As hypothesized, identity exploration was associated with lower odds of alcohol and cannabis co-use relative to alcohol only use (in post-hoc analyses unadjusted for private regard). This suggests that racial identity exploration may help prevent riskier patterns of substance use beyond the influence of traditional individual and interpersonal factors. Previous research suggests that African American adolescents who report higher levels of exploration may receive more racial socialization messages from their parents and community that reduce substance use by inhibiting associations with peers who use substances (Grindal & Nieri, 2016; Wallace & Fisher, 2007). It is possible that racial socialization messages that encourage behavioral engagement with one’s racial group and background may also promote engagement in structured activities, which are associated with lower substance use behaviors among adolescents (Spillane et al., 2020). Taken together, these findings point to the need for substance use prevention strategies for African American youth that facilitate behavioral engagement with their community and culture to reduce substance use and prevent the development of riskier substance use patterns, including concurrent alcohol and cannabis use.

Although racial identity exploration was associated with lower risk for concurrent alcohol and cannabis use relative to single substance use beyond the influence of traditional factors, divergent associations were observed for the other dimensions of racial identity. Private regard was not associated with concurrent use whereas public regard was associated with greater risk for concurrent use relative to non-use and alcohol-only use. The null results for private regard contrast previous research demonstrating that private regard is consistently associated with lower substance use intentions and behavior among African American youth (Rivas-Drake, Seaton, et al., 2014; Zapolski et al., 2019). However, most previous studies have examined substance use frequency, particularly alcohol use frequency (Caldwell et al., 2004; Nasim et al., 2007). It is possible that private regard is associated with alcohol use frequency but does not distinguish heterogeneous substance use patterns. Alternatively, we may not have been able to detect effects for private regard as adolescents in our sample consistently reported high levels of private regard with low variability.

The positive association between public regard and concurrent alcohol and cannabis use was inconsistent with previous research demonstrating a promotive association between public regard and lower engagement in substance use among African American adolescents (Zapolski et al., 2019). Although public regard among African American adolescents has been directly associated with promotive psychosocial outcomes (Rivas-Drake, Seaton, et al., 2014), in the context of racial discrimination, high public regard has been associated with poor psychological outcomes relative to low public regard (Sellers et al., 2006). Similarly, African American youth with high public regard have been found more vulnerable to substance use than those with low public regard when faced with experiences of racial discrimination (Anderson et al., 2020; Fuller-Rowell et al., 2012). It is possible that African American youth with high levels of public regard are more likely to use alcohol and cannabis as means to reduce stress associated with real world events (e.g., racial discrimination, police brutality) that challenge their belief that others in society view African Americans, including themselves, positively (Gerrard et al., 2012). Another possibility is that African American youth with low public regard, who believe that others view their race negatively, may be more vigilant in avoiding behaviors that elicit negative stereotypes, including cannabis or multiple substance use (Kwate et al., 2003; Zapolski et al., 2014).

The current study should be evaluated in light of the following limitations. First, the design of the current survey study was cross-sectional so we cannot confirm any causal relationships between examined factors; however, previous studies have demonstrated prospective relationships between many of the examined traditional factors and adolescent substance use. The study design also was not intended to select a representative sample so the current estimates cannot be generalized to the population of African American adolescents.

Second, this study operationalized concurrent use based on past-30-day substance use. It is probable that several participants in the non-use, alcohol only, and cannabis only groups use another substance occasionally, which limits the generalizability of our findings to more sporadic concurrent alcohol and cannabis use. Third, our measures demonstrated limitations. The measure for public regard had low reliability, although it was consistent with previous studies utilizing this measure (Constantine et al., 2002; Wallace & Fisher, 2007). The measure for substance use beliefs only asked participants how much risk was associated with use and did not include perceived benefits. This is particularly relevant for cannabis use beliefs, as adolescents often believe cannabis has benefits (e.g., Roditis & Halpern-Felsher, 2015). Although prior studies have demonstrated a strong relationship between the MEIM’s ethnic identity and measures of racial identity among African Americans, the MEIM asks respondents to assess their own ethnic identity, which could represent a different psychological construct than racial identity. Fourth, there were limitations to the current data that may have reduced power to detect effects. We observed a ceiling effect in the measure for private regard, which has been observed in previous studies among African Americans due to social desirability concerns (Ashburn-Nardo et al., 2003). Additionally, the size of the substance use groups varied significantly, with a small subsample size for the cannabis only group, which likely reduced statistical power. Finally, although we included traditional risk and resilience factors at multiple levels of youth’s ecology, the parent study did not include certain indicators that may be particularly relevant to understanding concurrent substance use behaviors among African American adolescents. For instance, we included indicators of both parent and peer support, but did not examine peer or parent substance use, which have been consistently associated with patterns of concurrent substance use in recent reviews (Halladay et al., 2020; Tomczyk et al., 2016). We also did not include racial discrimination, a key race-related cultural factor in the development of substance use among African American adolescents that may also help us better the relationships between dimensions of racial identity and substance use patterns (e.g., Fuller-Rowell et al., 2012; Hurd et al., 2014).

Conclusion

Although the field has recently attended to how and why adolescents use substances in combination, African American adolescents have largely been excepted despite demonstrating recent increases in concurrent alcohol and cannabis use and the highest rate of cannabis of any racial/ethnic group (Lanza et al., 2015; Miech, Johnston, et al., 2019). The current study integrated traditional and cultural factors to better understand alcohol and cannabis co-use among African American youth, taking a perspective that considers compositional differences (e.g., differences in exposure to factors) and process differences (e.g., differences in the impact of factors) in substance use development among this group (e.g., Watt, 2008). Results suggest that cultural factors influence engagement in substance use patterns among African American youth beyond the influence of traditional factors. What remains unknown is how cultural factors such as racial identity may mitigate or exacerbate the influence of traditional factors on substance use. Future research must continue to examine individual and interactive contributions of ecological factors, including race-related factors, in order to identify modifiable factors that promote youth development and mitigate disparities related to concurrent substance use across the lifespan.

Public Health Significance Statement.

This study found that universal psychological factors like conduct problems and positive beliefs about substance use are related to alcohol and cannabis co-use among African American adolescents. The study highlights the importance of considering not only universal factors, but also race-related factors, when trying to understand alcohol and cannabis co-use among this group. Specifically, the meaning and significance African American adolescents ascribe to their race may help explain why they engage in certain substance use patterns.

Author Note:

This work was supported in part by the National Institutes of Health (NIH) under grants R25 DA035692 (PI: Milburn, Wyatt) to Devin Banks and T32 MH18869 (PI: Danielson, Kilpatrick) to Donte Bernard. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Data reported in this manuscript were presented at the Research Society on Alcoholism’s 2021 meeting. Data reported also were collected as part of a larger data collection, findings from which have been reported in 17 published manuscripts. Two of those examined the subsample described in the current study and are referenced in the current manuscript (Arsenault et al., 2018; Banks et al., 2020).

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