Despite being largely preventable, adolescent substance use remains a major contributor to morbidity and mortality in the US. Recent increases in overdose deaths among youths highlight the urgency of identifying scalable, population-level prevention strategies.1,2 Because adolescent substance use commonly involves alcohol, nicotine, and cannabis, population-level prevalence of these behaviors is central to prevention.3,4
Schools represent a near-universal prevention platform. National data show variation in school mental health and substance use education,5 and evidence supports targeted approaches such as school-based screening and brief intervention and personality-targeted prevention programs.6-8 Less is known about whether routine, policy-driven health education delivered through standard coursework is associated with population-level substance use. This gap is important because routine coursework is scalable and institutionalized.
California law requires schools to provide instruction on alcohol, tobacco, nicotine, and other drugs, but does not prescribe the course structure through which this instruction must be delivered. Districts and schools retain flexibility in whether required content is delivered through a dedicated, transcriptable health course or integrated into other coursework. This policy context creates an opportunity to evaluate whether sustained availability of a dedicated health course is associated with lower adolescent substance use prevalence.
The analytic sample in thii study included 1 942 640 student survey responses from 915 public high schools across 345 districts and 3499 school years; mean (SD) grade was 10.1 (1.0), and 942 180 responses (48.5%) were from female students. Sustained availability of a dedicated health course was associated with lower school year prevalence of vaping (−1.36 [95% CI, −2.15 to −0.57] percentage points), marijuana use (−1.22 [95% CI, −1.95 to −0.49] percentage points), alcohol use (−1.11 [95% CI, −1.91 to −0.30] percentage points), and binge drinking (−0.70 [95% CI, −1.17 to −0.24] percentage points). Estimates for drug use, prescription drug misuse, and cigarette smoking were smaller.
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