By German Lopez
Don’t believe it? The available data from the Centers for Disease Control and Prevention (CDC) shows tobacco, alcohol, and opioid-based prescription painkillers were responsible for more direct deaths than any other drug in 2011. This chart compares those drug deaths with the best available data for cocaine, heroin, and marijuana deaths:
Now, this chart isn’t a perfect comparison across the board. One driver of tobacco and alcohol deaths is that both substances are legal and easily available. Other substances would likely be far deadlier if they were as available as tobacco and alcohol. (Heroin-linked deaths in particular have been trending up since 2010, topping 8,200 in 2013 and making heroin deadlier overall than cocaine.) And federal data excludes some deaths, particularly less direct illicit drug deaths, which is why the chart focuses on direct health complications for all drugs.
But the absolute numbers show legality doesn’t indicate safety. Here’s what makes tobacco, alcohol, and prescription painkillers so dangerous, and how policymakers can curb the problem.
When it comes to deadliness, no single substance comes close to tobacco. To put its risk in perspective, fewer Americans die from reported drug overdoses, traffic accidents, and homicides combined than tobacco-caused health problems like lung cancer and heart disease.
Cigarette smoking is linked to one in five deaths in the US each year, according to the CDC. Nearly 42,000 of the 480,000 deaths are caused by secondhand smoke.
US tobacco use has greatly declined in the past several decades, although nearly one in five high school students and adults still smoked cigarettes in 2011. Experts attribute the decline to various factors, including education campaigns, mandatory warning labels, public and workplace smoking bans, and higher taxes on tobacco products.
Alcohol-induced health problems, such as liver disease, led to more than 26,000 deaths in 2011. But that actually under-counts the number of deaths caused by alcohol: when including other causes of death like drunk driving and other accidents, the toll rises to 88,000 per year.
Even this higher number may understate the more general risk of alcohol. A previous report published in The Lancet took a comprehensive look at 20 of the world’s most popular drugs and the risks they pose in the UK. A conference of drug experts measured all the factors involved — mortality, other physical damage, chance of developing dependence, impairment of mental function, effect on crime, and so on — and assigned each drug a score. What they concluded: alcohol is by far the most dangerous drug to society as a whole.
What makes alcohol so dangerous? The health effects of excessive drinking and drunk driving are two obvious problems. But there are other major issues rooted in alcohol-induced aggression and erratic behavior: injuries, economic productivity costs, family adversities, and even crime. (Alcohol is a factor in 40 percent of violent crimes, according to the National Council on Alcoholism and Drug Dependence.)
The Lancet‘s report comes with a couple caveats. It doesn’t entirely control for the availability of these drugs, so it’s possible heroin and crack cocaine in particular would be ranked higher if they were as readily available as alcohol. And the findings are based on the UK, so the specific scores would likely differ to some extent for the US.
To curb these deaths, experts often suggest tighter regulations, taxes, and more education. Previous research found that states that sold alcohol through tightly regulated, state-run establishments kept prices higher, reduced access for youth, and decreased drinking overall. And studies show that higher alcohol taxes could reduce consumption and, as a result, the problems the drug causes.
3) Prescription painkillers
Opioid-based prescription painkillers have been linked to an increase in overdose deaths since 1999. These deaths frequently involve multiple drugs; the CDC found 31 percent of prescription painkiller-linked overdose deaths in 2011 were also related to benzodiazepines, a legal anti-anxiety drug.
Whether these prescription painkiller deaths amount to an “epidemic,” as some local, state, and federal officials claim, is a matter of semantic debate in drug policy circles. Regardless of what one labels it, the general point is that prescription painkillers are linked to thousands of deaths each year. (Radley Balko, now of the Washington Post, wrote a great three–part series on the debate around this topic.)
Policymakers have responded to the deaths by putting tighter restrictions on the distribution of prescription painkillers and cracking down on “pill mills,” or doctors, clinics, and pharmacies that dispense prescription painkillers unscrupulously or for non-medical reasons.
But some research found that these types of crackdowns have pushed some drug users to the more potent and dangerous heroin, indicating that there’s a careful balance to strike as policymakers consider more restrictions on prescription painkillers.
There’s also concerns that restricting painkillers too much makes it more difficult for people to get the medicine they genuinely need for chronic, debilitating pain. A 2011 report from the Institute of Medicine found that many Americans are under-treated for chronic pain. And multiple reports suggest doctors have avoided working in chronic pain treatment because the legal and regulatory hurdles are so big.
One way to reduce prescription painkiller deaths may be medical marijuana. One study found that states that allow pot for medicinal purposes have fewer prescription painkiller deaths than one would otherwise expect. Intuitively, this makes sense: marijuana is a potent painkiller, so it can substitute for deadlier and more addictive opioids. But experts caution this field of research needs much more study to see how much of the relationship between medical pot and prescription painkillers is causation instead of correlation.
What about illicit drugs?
There’s admittedly no good federal mortality data on the less direct and long-term impacts of illicit drug use. But there are a few reasons to think the scale of overall deadliness in the chart at the top wouldn’t change much with additional data.
Tobacco is much, much deadlier than all the other drugs combined, based on the current federal numbers. It’s hard to imagine anything making up for this massive disparity.
Other research suggests the addition of indirect deaths would look worse for alcohol than other drugs. One study found alcohol increases the risk of fatal traffic accidents by nearly 14 times, while marijuana increases the risk by less than double and narcotics by roughly three times, suggesting alcohol is much more likely to cause accidental deaths than other substances.
The deadliness of the harder drugs, like crack and cocaine, is also limited in part because very few people use such substances, especially in the long-term. About 0.1 percent of the US population 12 and older reported using heroin and roughly 0.6 percent reported using cocaine in the past month, a 2013 federal survey found. (This could change if the illicit drugs were legal and more accessible.)
With marijuana use in particular, it’s not yet clear what the long-term effects are. The research suggests using marijuana during adolescence could lead to some bad outcomes, particularly worse cognitive function. But studies have failed to conclusively link marijuana to lung disease or psychosis and schizophrenia, despite concerns from critics.