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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: J Adolesc. 2022 Nov 7;95(2):372–381. doi: 10.1002/jad.12119

Religious Affiliation Protects Against Alcohol/Substance Use Initiation: A Prospective Study Among Healthy Adolescents

David H Rosmarin 1,2,*, Steven Pirutinsky 3,§, Caroline C Kaufman 1,2, Sion K Harris 4,5, Jennifer T Sneider 1,6, Marisa M Silveri 1,6
PMCID: PMC9908826  NIHMSID: NIHMS1847291  PMID: 36345114

Abstract

Background:

A substantial volume of literature suggests that religious factors buffer against alcohol/substance use among adults, but research among adolescents is sparse. Further, few studies in this area have been prospective, and therefore it is unclear how religion may impact less alcohol/substance use among adolescents.

Method:

We prospectively evaluated effects of religious affiliation on initiation of alcohol/substance use in a sample of 81 psychiatrically healthy 13–14-year-olds from New England, over a three-year period (from November 2015 to January 2019). Known risk factors were also evaluated including anxiety, depression, and impulsivity; family history of mental illness and alcohol/substance misuse; and volume of brain regions implicated in adolescent alcohol/substance misuse (assessed by Magnetic Resonance Imaging).

Results:

Religiously affiliated adolescents were significantly less likely to initiate use of alcohol/substances (HR = .38). Addition of family history of alcohol/substance misuse to the model increased the predictive value of religious affiliation (HR = .34). Other risk factors did not diminish nor increase observed effects.

Conclusions:

These findings support and extend the current research by suggesting that religious affiliation protects against initiation of alcohol/substance use during early adolescence, particularly in individuals with elevated risk.

Keywords: religion, spirituality, adolescence, structural MRI, risk factors, AUD, SUD

Introduction

Adolescence is a critical period of risk for initiation of alcohol/substance use; multiple studies show associations between earlier age of first use and greater likelihood of developing alcohol/substance use disorders (Dawson, 2006; Infante et al., 2020; King & Chassin, 2007; Lopez-Quintero et al., 2010; Swendsen et al. 2012; Welty et al., 2017). Furthermore, adolescents are particularly prone to initiate alcohol and other substance use due to heightened mental health issues (Corneau et al., 2001; Pang et al., 2014) and greater impulsivity (Ernst et al., 2006), which commonly occur during this developmental period (Lisdahl et al. 2018). These factors can, at least partially, be explained by unique patterns of neurobiological maturation during adolescence, including the concurrent curvilinear development of subcortical regions alongside linear development of prefrontal regions (Casey & Jones, 2010). Along these lines, several areas of neuroanatomy are known to be implicated in adolescent alcohol and substance use, including the medial orbitofrontal cortex (mOFC), dorsal striatum (caudate, putamen), cingulate cortex, and insula (Cheetham et al., 2012; Cheetham et al., 2017). Neural and other risk factors (Kim-Spoon et al., 2019; Martz et al. 2018) for alcohol and substance use are known to be more prominent in the context of familial history of mental illness and alcohol/substance use disorders (Handley et al. 2013; Van Loon et al., 2014), which are increasingly common today (Substance Abuse and Mental Health Services Administration, 2020). It is important to examine social factors or experiences that may help protect against initiation of alcohol and substance use among adolescents, particularly for individuals with higher risk profiles.

Religious affiliation and involvement are known to be strong protective factors against problematic use of alcohol/substances among adults (Conner & Devido, 2020; Kendler & Meyers, 2009; Michalak et al., 2007); religiously involved adults appear to have 20–30% reduced risk for alcohol or drug dependence (Kendler et al. 2003). Further, the statistical majority of adults who have recovered from an alcohol/substance use disorder have participated in interventions that have spiritual components, such as Alcoholics Anonymous (Kelly et al., 2020). While mechanisms underlying these effects remain unclear due to a lack of research, one prominent theory suggests that religion can buffer against impulsivity and sensation-seeking by accustoming religious individuals to delayed gratification and facilitating greater self-control (McCullough & Carter, 2013; Miller & Van Ness Sheppard, 2014). Research on religion and alcohol/substance use among adolescents is more limited, but a number of studies have shown inverse associations between various facets of religious life and risk-taking activities including use of alcohol and drugs (Knight et al. 2007; Miller et al. 2000; Russell et al., 2020; Sinha et al. 2007). Moreover, the majority of studies among adults – and all studies known to us among adolescents – have not utilized prospective designs. It is therefore unclear the degree to which religion is associated with lower rates of alcohol/substance use and use disorders among adolescents. Further, the extent to which religious affiliation might protect against initiation of alcohol/substance use among healthy adolescents is not known, and whether religion buffers against initiation in the context of known risk factors (e.g., mental distress, impulsivity, family history of mental disorders or alcohol/substance abuse, neural risk factors) is similarly unclear.

Over a three-year period, the current study examined the prospective effect of having a religious affiliation at baseline on subsequent initiation of alcohol/substance use among 13- to 14-year-old adolescents who, at study start, screened negative for significant psychiatric and medical histories and had not yet used alcohol (“more than a few sips”) or substances (any use at all). We also examined the effect of religious affiliation on risk of alcohol/substance use initiation in the context of known intrapsychic (e.g., anxiety, depression, impulsivity), familial (e.g., family history of alcohol/substance use disorder), and neural (e.g., brain morphometry) risk factors. Given previous research, we hypothesized that religious affiliation would provide a buffer against the initiation of alcohol/substance abuse in this sample, and that protective effects would be greater for adolescents with heightened risk.

Methods

Participants and Procedures

The study sample consisted of 81 psychiatrically healthy adolescents, recruited from New England between November 2015 and January 2019, who were alcohol and substance naïve at the start of the study (see Table 1 for baseline descriptive values of all study variables). Online social media platforms (e.g., Facebook), local flyers, and patient registries via partnership with Boston Children’s Hospital, were utilized for study recruitment. To determine eligibility for the study, interested adolescents completed a computerized questionnaire via Research Electronic Data Capture (REDCap, a secure online database for administering surveys and organizing responses) (Harris et al., 2009), as well as a screening process which included collection of a medical, alcohol/drug use, and psychiatric history. A phone interview was then administered to parents/guardians to confirm medical and psychiatric history questions. Parents and adolescents provided consent and assent, respectively, prior to participation, and adolescents were monetarily compensated for participation. The research protocol was approved by the Massachusetts General Brigham Institutional Review Board.

Table 1.

Participant Demographics

Variable Total Sample (n = 81) M(SD) or %
Family History of Depression 66.7% Yes
Family History of Anxiety 51.9% Yes
Family History of Alcohol/Substance Abuse 33.3% Yes
Age (years) 13.78 (0.61), range: 13.04–14.98
Anxietya 43.87 (15.02), range: 10–72
Depressionb 10.90 (9.24), range: 0–43
Impulsivityc 61.72 (9.35), range: 33–86
Sex Assigned at Birth 51.9% Female
48.1% Male
Ethnicity 96.3% Non-Hispanic
Race 75.3% White/European American
13.5% Multi-racial
4.9% Asian
2.5% African American/Black
2.5% Not reported
1.2% Native Hawaiian/Other Pacific Islander
Religious Affiliation 66.7% Religiously Affiliated
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Notes: Data represent means ± standard deviation. Abbreviations:

a

MASC, Multidimensional Anxiety Scale for Children (possible range: 0 −117)

b

The Center for Epidemiological Studies—Depression Scale for Children (possible range: 0 −60)

c

Barrett Impulsiveness Scale (possible range: 30 −120);.

At each study visit, procedures included self-report measures, structured clinical interviews, and magnetic resonance imaging (MRI). Participants were excluded from the study based on a number of criteria at the outset of the study including: Any history of or current diagnosed psychiatric illness; any history of or current alcohol/substance use (more than a “few sips” of alcohol and/or any psychoactive substance use); pregnancy; or MRI contraindications such as serious physical health complications, history of head injury with loss of consciousness, or presence of radiologic brain abnormalities, at baseline. In addition, at each study visit, all adolescents underwent urine screening prior to scanning to rule out alcohol/substance use (Clarity Diagnostics Drugs of Abuse Panel, Boca Raton, FL) and/or pregnancy (QuPID One-Step Pregnancy, Stanbio Laboratory, Inc., San Antonio, TX, United States). At the start of the study, all adolescents reported no significant psychiatric history, however over the course of the study, three participants retroactively endorsed the possible presence of psychiatric symptoms prior to the first study visit.i Our main study results were similar when these participants were excluded from analyses; they were therefore retained in the sample to maintain statistical power based on responses provided at the point of initial screening (results of these additional analyses are reported below). Participants were enrolled into the study prior to the initiation of alcohol or other substance use at 13–14 years of age and were then followed for three years via quarterly online surveys to assess initiation of alcohol/substance use. Those who went on to endorse alcohol/substance use prior to reaching age 16 were classified as initiators and those who reached age 16 without having endorsed alcohol/substance use were classified as non-initiators.

Clinical and Self-Report Measures

Alcohol/Substance Use.

Participants were asked to report their frequency of alcohol and/or substance use (over the last three months), via confidential surveys using REDCap. Specifically, participants were asked about alcohol, marijuana, cigarettes or other tobacco products, and for “any other type of drug that was not prescribed to you by a doctor.” Response options for each category were “Never,” “Only a few times,” “1–3 times per month,” “1–5 times per week” or “Daily.”34 Participants were told their responses would be kept confidential and not reported to their parents. In addition, at each study visit, all adolescents underwent urine screening prior to scanning to rule out alcohol/substance use (Clarity Diagnostics Drugs of Abuse Panel, Boca Raton, FL). Parents of adolescent participants were assessed via a Family History Epidemiologic interview administered at baseline to assess family history (i.e., one or both biological parents or any grandparents) of alcohol/substance use, depressive and/or anxiety disorders.

Religion.

Participants reported if they affiliated with a religious group (Yes or No). As a validity check, we also administered items assessing importance of religion (0–5 “not at all” to “very”), frequency of religious service attendance (0–6, “never” to “more than once a week,”) and belief in God (0–4, “strongly disagree” to “strongly agree.”) Religiously affiliated adolescents reported significantly greater importance of religion, frequency of service attendance, and belief in God (t(79) ranging from 6.6–7.2, p > .001 for all analyses)

Demographics.

We administered a brief demographic survey to obtain information regarding age, sex assigned at birth and gender identity.

Psychiatric Disorders.

The Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), a structured clinical interview, was used to assess presence of psychiatric disorders (Sheehan et al., 2010) in the sample.

Depression.

The Center for Epidemiological Studies—Depression Scale for Children (CES-DC) was used to assess depressive symptoms among adolescents (Fendrich et al., 1990). The CES-DC is a 20-item self-report assessment of depressive symptoms across a variety of domains. Reliability for the current study was high (α = .91).

Anxiety.

The Multidimensional Anxiety Scale for Children was used to assess anxiety symptoms among adolescent participants (March et al., 1997). The MASC is a 39-item self-report measure that assesses anxiety symptoms across the following domains: physical symptoms, social anxiety, harm avoidance, anxious coping, and separation anxiety. Reliability for the sample was high (α = .91).

Impulsivity.

The Barratt Impulsiveness Scale (BIS) was used to assess impulsive personality traits among adolescents (Patton et al. 1995). The BIS is a self-report measure with 30-items to assess impulsivity attentional, motor, and non-planning domains, as well as components of self-control, cognitive complexity, perseverance, and cognitive instability. Reliability for the sample was adequate (α = 80).

Magnetic Resonance Imaging Acquisition and Processing

Magnetic resonance imaging data on brain volume were acquired at baseline using a Siemens TIM Trio 3.0 Tesla MRI system (Erlangen, Germany) with a 32-channel head coil. High resolution structural images were obtained using a T1-weighted multi-echo magnetization prepared rapid acquisition gradient echo (ME-MPRAGE) 3D sequence in 4 echoes. The following parameters were utilized: TE = 1.64/3.5/5.36/7.22 ms, TR = 2.1 seconds, TI = 1.1 seconds, FA = 12°, 176 slices, 1 mm x 1 mm x 1.3 mm voxel size, acquisition time = 5 minutes. T1-ME-MPRAGE images were labeled, segmented, and analyzed utilizing FreeSurfer version 6.0 semi-automated reconstruction pipeline (Fischl, 2012; Fischl, 2002). Full structural analysis details have been previously reported (Maksimovskiy, 2019). In general, all structural MRI data were manually inspected and edited to confirm high image quality. Manual edits were applied to the brainmask file and mainly consisted of adjustments to pial surfaces to exclude dura matter (all files) and a minimal number of edits in which pial surfaces were adjusted to expand the white matter surface. Volumetric files (aseg and subfield volumes) were inspected for accuracy of reconstruction, and no edits were made. All brain regions were adjusted for each individual’s respective head size using a measure generated by FreeSurfer, estimated total intracranial volume (eTIV). In this study, we analyzed volume measures of key brain regions including medial orbitofrontal cortex, dorsal striatum (caudate, putamen), cingulate cortex, and insula. Of note, structural MRI data was obtained for all adolescents in the study, but at the time of analyses processing of variables was only completed for 65 participants, due to pandemic-related staffing shortages. Pairwise deletion was used to remove participants with missing data from the relevant analysis.

Statistical Modeling

To test our primary hypothesis that religious affiliation would lower the risk of substance use initiation, we estimated a series of Cox Proportional Hazards Models (Cox, 1972). These models assessed the degree to which the probability of initiation occurring before a particular time was proportional to predictor variables. The dependent variable in this analysis was the number of days from the start of the study elapsing prior to initiation of alcohol/substance use, and data were considered censored if no initiation occurred prior to the end of data collection. Following the recommendations of Grambsch and Therneau (1994), assumptions for these models such as proportional hazards, the absence of influential outliers, and linearity were assessed using Schoenfeld, deviance, and martingale residuals respectively. Analyses began with a basic model that included key demographic covariates (i.e., initial age and gender) as predictors of time to initiation of alcohol/substance use. We then added religious affiliation in a second model (Model 2). Finally, to assess the relative contribution of religious affiliation over and above other previously established risk factors, we estimated additional models that included individual mental health (Model 3: impulsivity, depression, anxiety), family history of alcohol/substance misuse (Model 4), and volume of key brain regions (Model 5) including the medial orbitofrontal cortex, dorsal striatum (caudate, putamen), cingulate cortex, and insula. We then tested if these models explained a significant proportion of the variance in risk above and beyond the baseline model described above, and we evaluated effects of religious affiliation within each model. To provide a conservative evaluation of effects, each set of risk factors was examined independently. Models were compared using loglikelihood ratio-based chi-square tests, and coefficients were evaluated using Wald statistics, and statistical analyses were conducted using SPSS 24.0 and the survival (Therneau & Lumley, 1994) and survminer (Kassambara et al., 2017) packages in R Statistical Computing (R Core Team, 2013).

Results

Approximately two-thirds of the sample (66.7%) reported affiliation with a religious group. Results of the basic model indicated that 30/81 (37%) of participants initiated alcohol/substance use over the course of the study, with risk increasing linearly over time. The remaining 51 (63%) did not initiate. In the basic model, baseline age (HR = 1.83, 95%CI: .997 – 3.37, Wald = 3.81, p = .051) and sex (HR = .90, 95%CI: .44 – 1.85, Wald = .09, p = .77) did not significantly increase risk in our sample. The addition of religious affiliation (Model 2) significantly improved fit (χ2(1) = 6.38, p = .012), and examination of coefficients suggested that participants reporting a religious affiliation were significantly less likely to initiate substance use over the course of the study (HR = .38, 95% CI: .18 – .79, Wald = 6.71, p = .01; Table 2; Figure 1). These results were similar when we excluded the three participants who retroactively reported the possible presence of psychiatric symptoms (HR = .44, 95% CI: .20 – .94, Wald = 4.49, p = .03).

Table 2.

Cox Proportional Hazard Models for Religious Affiliation (N = 81)

B SE Wald df p HR 95%CI for HR
Initial Age .62 .31 4.08 1 .04 1.85 1.02 – 3.36
Sex −.23 .38 .38 1 .54 0.79 0.38 – 1.66
Religious Affiliation .97 .37 6.71 1 .01 2.63 1.27 – 5.47
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Figure 1.

Figure 1.

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Initiation of Alcohol/Substance Use among Religiously Affiliated and Unaffiliated Adolescents

Note: Cumulative Hazard represents the cumulative risk of initation at or prior to each specific time point.

To assess the relative effect of religious affiliation as a predictor of alcohol/substance use initiation over and above other established risk factors, we conducted a series of additional models that included various risk factors in the model along with religious affiliation (see Table 3). Results indicated that adding family history of alcohol/substance use, anxiety, and depression did not significantly improve model fit (χ2(3) = 2.00, p = .57), and none of these individual variables significantly predicted initiation. In fact, the addition of these covariates descriptively increased the predictive value of religious affiliation (HR = .34, 95%CI: .16 - .73, Wald = 7.67, p = .006) suggesting that religious affiliation was a better predictor of (less) alcohol/substance initiation when family-related risk level was held constant, although the difference between these coefficients was not statistically significant (t(140) = .33, p = .74). Results were similar for individual factors (i.e., impulsivity, anxiety, and depression); the addition of these variables did not improve model fit (χ2(3) = 6.05, p = .11), none were significant predictors of alcohol/substance initiation, and affiliation retained its predictive values (HR = .47, 95%CI: .22 –.996, Wald = 3.89, p = .05). Finally, the addition of regional brain volume at baseline (medial orbitofrontal cortex, dorsal striatum, cingulate cortex, and insula) similarly did not improve model fit (χ2(18) = 6.06, p = .06), and religious affiliation retained its significance in this model (HR = .34, 95%CI: .2913 – .88, Wald = 4.87, p = .03). Results for all these models were similar when we excluded three participants who retroactively endorsed possible psychiatric illnesses.

Table 3.

Comparison of Cox Proportional Hazard Models (n=65–81)

N (Event/Censored) −2LL χ 2 df p
Model 1 (baseline)
Model 2 (religious affiliation) 30/45 219.29
Model 3 (individual factors) 30/45 213.24 6.05 3 .11
Model 4 (family history) 30/45 217.29 1.99 3 .57
Model 5 (regional volume) 27/44 186.36 6.06 18 .64
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Note: χ2 statistics compare each model to Model 2, which included initial age, sex, and religious affiliation.

Discussion

In this three-year prospective study among healthy adolescents, religiously affiliated 13–14-year-olds were approximately 2.6 times less likely to initiate alcohol/substance use. The potentially protective role of religious affiliation was robust and endured when controlling for age and gender, as well as known intrapsychic and familial risk factors. In fact, descriptive effects of religious affiliation increased once family history of mental distress and alcohol/substance use was added to our statistical model. These findings are consistent with prior literature indicating that religion has a protective role against alcohol/substance initiation and use among adults and youth (Kendler & Myers, 2009; Machalak et al., 2007; Connery & Devido, 2020). However, these results also extend prior literature given the prospective design of the current study, and the inclusion of multiple risk factors including known neural correlates of alcohol/substance use among adolescents.

What might account for our results? It has been proposed that spirituality and religion can buffer against impulsivity and sensation-seeking experiences by enhancing self-control (McCullough & Willoughby, 2009). Indeed, this proposed relationship has been demonstrated among youth (Desmond et al., 2013). For adolescents in particular, religious affiliation may accomplish this via social networks (Hodge et al., 2011). For example, religiously affiliated youth may have more access to peers who abstain from, or use less, alcohol and other substances, and social activities within this context may be less likely to include use. Religious engagement may thereby provide youth with models of alcohol/substance abstinence, and less peer-pressure. In addition, religious affiliation may provide opportunities for meaning- or value-based behavior (e.g., volunteering, leadership) that are commonly associated with spiritual or transcendent significance (Hodge et al., 2011). Such behavior may create less time, opportunity or urges to engage in alcohol or substance use behaviors. Furthermore, religious identity may be incongruent or dissonant with alcohol/substance use.

The current study has several limitations that must be noted. First, our study was among healthy adolescents, and findings do not necessarily generalize to adolescents with psychiatric symptoms or diagnoses. This is an important limitation given increasing rates of mental health concerns among adolescents (Leeb et al., 2020). Second, our study extends what is known regarding the relationship between brain volume, religious affiliation, and alcohol/substance use initiation, but future research examining additional neurobiological markers (e.g., functional activation and network brain connectivity, neurochemistry, etc.) is warranted. Third, our findings expand the understanding of a social-religious experience to a mental health phenomenon, however our study design does not allow for translation of findings into clinical or preventative interventions. Another potential limitation was the use of urine screenings and self-report to identify initiation, which may have been more effective for identification of substance vs. alcohol use. Future research may include additional screenings (e.g., hair, saliva) to objectively identify recent alcohol use. Finally, while sample size is a limitation of our study that should be addressed in future research, these findings provide critical foundational information for future studies aimed at replication in a larger sample. Despite these limitations, the results of the current study are novel and among the first of their kind to reveal the important relevance of religious affiliation as a protective mechanism against growing mental health issues – alcohol/substance use among adolescents – particularly in the context of well-established risk factors, such as family history.

Supplementary Material

Appendix

Funding Statement:

Financial support was received from McLean Hospital development fund (#041537), NIAAA grant R01 AA022493 (Silveri), and NIAAA grant K24 AA025977 (Silveri).

The authors jointly affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Participants were assured raw data would remain confidential and would not be shared. Financial support was received from McLean Hospital development fund (#041537), NIAAA grant R01 AA022493 (Silveri), and NIAAA grant K24 AA025977 (Silveri).

Footnotes

Ethics Approval Statement:

The study received IRB approval.

Patient Consent Statement:

Participants provided informed consent and were assured raw data would remain confidential and would not be shared.

Permission to reproduce material from other sources if any: N/A

i

One had a chromosomal abnormality and related learning disability; another reported a diagnosis of Attention Deficit Hyperactivity Disorder; a third had a provisional diagnosis of an unspecified mood disorder.

Conflict of Interest Disclosure:

The authors have no conflicts of interest to disclose.

Data Availability Statement:

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix
NIHMS1847291-supplement-Appendix.docx (26.9KB, docx)

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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