Additional Information

Drug overdose deaths in the United States continue to increase in 2015

Drug overdose deaths and opioid-involved deaths continue to increase in the United States. The majority of drug overdose deaths (more than six out of ten) involve an opioid.¹  Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled.² From 2000 to 2015 more than half a million people died from drug overdoses. 91 Americans die every day from an opioid overdose.

We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled,² yet there has not been an overall change in the amount of pain that Americans report.^3,4 Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999.⁵

Heroin use is trending up

From 2002–2013, past month heroin use, past year heroin use, and heroin addiction have all increased among 18-25 year olds.⁶ The number of people who started to use heroin in the past year is also trending up. Among new heroin users, approximately three out of four report abusing prescription opioids prior to using heroin.⁷ The increased availability, lower price, and increased purity of heroin in the US have been identified as possible contributors to rising rates of heroin use.^8,9 According to data from the DEA, the amount of heroin seized each year at the southwest border of the United States was approximately 500 kg during 2000–2008. This amount quadrupled to 2,196 kg in 2013.¹⁰

Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015. The largest increase in overdose deaths from 2014 to 2015 was for those involving synthetic opioids (other than methadone), which rose from 5,544 deaths in 2014 to 9,580 deaths in 2015. One of these synthetic opioids, illegally-made fentanyl, drove the increase.¹ It was often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge.

What can be done?

We need to improve prescribing of opioids, expand treatment of addiction, and reduce access to illegal opioids.

• Improve opioid prescribing to reduce exposure to opioids, prevent abuse, and stop addiction.
• Expand access to evidence-based substance abuse treatment, such as Medication-Assisted Treatment, for people already struggling with opioid addiction.
• Expand access and use of naloxone—a safe antidote to reverse opioid overdose.
• Promote the use of state prescription drug monitoring programs, which give health care providers information to improve patient safety and prevent abuse.
• Implement and strengthen state strategies that help prevent high-risk prescribing and prevent opioid overdose.
• Improve detection of the trends of illegal opioid use by working with state and local public health agencies, medical examiners and coroners, and law enforcement.

References

Underage Drinking

Alcohol is the most commonly used and abused drug among youth in the United States.¹

• Excessive drinking is responsible for more than 4,300 deaths among underage youth each year, and cost the U.S. $24 billion in economic costs in 2010.^2,3
• Although drinking by persons under the age of 21 is illegal, people aged 12 to 20 years drink 11% of all alcohol consumed in the United States.⁴ More than 90% of this alcohol is consumed in the form of binge drinks.⁴
• On average, underage drinkers consume more drinks per drinking occasion than adult drinkers.⁵
• In 2010, there were approximately 189,000 emergency rooms visits by persons under age 21 for injuries and other conditions linked to alcohol.⁶

Drinking Levels among Youth

The 2015 Youth Risk Behavior Survey⁷ found that among high school students, during the past 30 days

• 33% drank some amount of alcohol.
• 18% binge drank.
• 8% drove after drinking alcohol.
• 20% rode with a driver who had been drinking alcohol.

Other national surveys

• In 2015, the National Survey on Drug Use and Health reported that 20% of youth aged 12 to 20 years drink alcohol and 13% reported binge drinking in the past 30 days.⁸
• In 2015, the Monitoring the Future Survey reported that 10% of 8th graders and 35% of 12th graders drank during the past 30 days, and 5% of 8th graders and 17% of 12th graders binge drank during the past 2 weeks.⁹

Consequences of Underage Drinking

Youth who drink alcohol ^1,5,10 are more likely to experience

• School problems, such as higher absence and poor or failing grades.
• Social problems, such as fighting and lack of participation in youth activities.
• Legal problems, such as arrest for driving or physically hurting someone while drunk.
• Physical problems, such as hangovers or illnesses.
• Unwanted, unplanned, and unprotected sexual activity.
• Disruption of normal growth and sexual development.
• Physical and sexual assault.
• Higher risk for suicide and homicide.
• Alcohol-related car crashes and other unintentional injuries, such as burns, falls, and drowning.
• Memory problems.
• Abuse of other drugs.
• Changes in brain development that may have life-long effects.
• Death from alcohol poisoning.

In general, the risk of youth experiencing these problems is greater for those who binge drink than for those who do not binge drink.¹⁰

Youth who start drinking before age 15 years are six times more likely to develop alcohol dependence or abuse later in life than those who begin drinking at or after age 21 years.⁸

Prevention of Underage Drinking

Reducing underage drinking will require community-based efforts to monitor the activities of youth and decrease youth access to alcohol. Recent publications by the Surgeon General¹ and the Institute of Medicine⁵ outlined many prevention strategies for the prevention of underage drinking, such as enforcement of minimum legal drinking age laws, national media campaigns targeting youth and adults, increasing alcohol excise taxes, reducing youth exposure to alcohol advertising, and development of comprehensive community-based programs.

References:

1. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking. Rockville, MD: U.S. Department of Health and Human Services; 2007.
2. Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC.
3. Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 National and State Costs of Excessive Alcohol Consumption. Am J Prev Med 2015; 49(5):e73–e79.
4. Office of Juvenile Justice and Delinquency Prevention. Drinking in America: Myths, Realities, and Prevention Policy [PDF-1.03MB]. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 2005.
5. Bonnie RJ and O’Connell ME, editors. National Research Council and Institute of Medicine, Reducing Underage Drinking: A Collective Responsibility. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press, 2004.
6. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits [PDF-410KB]. Rockville, MD; 2012.
7. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2015. MMWR Surveill Summ 2016;65(No. SS-6):1–174.
8. Center for Behavioral Health Statistics and Quality. 2015 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD; 2016.
9. Johnston, LD, O’Malley PM, Miech RA, Bachman, J G, & Schulenberg J E. Monitoring the future national survey results on drug use, 1975-2015: 2015 Overview- Key findings on adolescent drug use [PDF-3.3 MB]. Ann Arbor, MI: Institute for Social Research, The University of Michigan.
10. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics 2007;119:76–85.

Electronic Nicotine Delivery Systems: Key Facts
CDC Office on Smoking and Health
October 2016

This document outlines key facts related to electronic nicotine delivery systems (ENDS), including e-cigarettes.

• Youth use of ENDS continues to rise rapidly in the U.S.
  • From 2011 to 2015, past 30-day use of e-cigarettes increased more than ten-fold for high school students (1.5% to 16.0%) and nearly nine-fold for middle school students (0.6% to 5.3%).
  • Nearly 2.5 million U.S. middle and high school students were past 30-day e-cigarette users in 2014, including about 1 in 7 high school students.
  • In 2013, more than a quarter of a million (263,000) middle and high school students who had never smoked cigarettes had ever used e-cigarettes.
• Most adult ENDS users also smoke conventional cigarettes, which is referred to as “dual use.”
  • In 2014, 3.7% of adults were past 30 day e-cigarette users, including 20.3% of conventional cigarette smokers. Among adult past 30 day e-cigarette users, 58.8% were also current cigarette smokers (i.e., “dual users”) in 2015.
• Nicotine poses dangers to pregnant women and fetuses, children, and adolescents. Youth use of nicotine in any form, including ENDS, is unsafe.
  • Nicotine is highly addictive.
  • Nicotine is toxic to developing fetuses and impairs fetal brain and lung development.
  • Because the adolescent brain is still developing, nicotine use during adolescence can disrupt the formation of brain circuits that control attention, learning, and susceptibility to addiction.
  • Poisonings have resulted among users and non-users due to ingestion of nicotine liquid, absorption through the skin, and inhalation.E-cigarette exposure calls to poison centers increased from one per month in September 2010 to 215 per month in February 2014, and over half of those calls were regarding children ages 5 and under.
  • According to the Surgeon General, the evidence is already sufficient to warn pregnant women, women of reproductive age, and adolescents about the use of nicotine-containing products such as smokeless tobacco, dissolvables, and ENDS as alternatives to smoking.
• Any combusted tobacco use at any age is dangerous.
  • The burden of death and disease from tobacco use in the U.S. is overwhelmingly caused by cigarettes and other combusted tobacco products.
  • There is no safe level of exposure to secondhand tobacco smoke.
• In order for adult smokers to benefit from ENDS, they must completely quit combusted tobacco use. Smoking even a few cigarettes per day is dangerous to your health.
  • Smokers who cut back on cigarettes by using ENDS, but who don’t completely quit smoking cigarettes, aren’t fully protecting their health:
    • Smoking just 1-4 cigarettes a day doubles the risk of dying from heart disease.
    • Heavy smokers who reduce their cigarette use by half still have a very high risk for early death.
  • Benefits of quitting smoking completely:
    • Heart disease risk is cut in half 1 year after quitting and continues to drop over time.
    • Even quitting at age 50 cuts your risk in half for early death from a smoking-related disease.
• ENDS are not an FDA-approved quit aid.
  • The evidence is currently insufficient to conclude that ENDS are effective for smoking cessation.
  • Seven medicines are approved by the FDA for smoking cessation, and are proven safe and effective when used as directed.
• ENDS aerosol is NOT harmless “water vapor” and is NOT as safe as clean air.
  • ENDS generally emit lower levels of dangerous toxins than combusted cigarettes. However, in addition to nicotine, ENDS aerosols can contain heavy metals, ultrafine particulate, and cancer-causing agents like acrolein.
  • ENDS aerosols also contain propylene glycol or glycerin and flavorings. Some ENDS manufacturers claim that the use of propylene glycol, glycerin, and food flavorings is safe because they meet the FDA definition of “Generally Recognized as Safe” (GRAS). However, GRAS status applies to additives for use in foods, NOT for inhalation. The health effects of inhaling these substances are currently unknown.
• ENDS are aggressively marketed using similar tactics as those proven to lead to youth cigarette smoking.
  • Although the advertisement of cigarettes has been banned from television in the United States since 1971, ENDS are now marketed on television and other mainstream media channels.
  • Spending on advertising of ENDS tripled each year from 2011 to 2013.Sales of ENDS also increased dramatically over a similar period.
  • In 2014, more than 18 million (7 in 10) U.S. middle and high school students were exposed to e-cigarette advertisements in retail stores, on the Internet, in magazines/newspapers, or on TV/movies.
  • ENDS marketing has included unproven claims of safety and use for smoking cessation, and statements that they are exempt from clean air policies that restrict smoking.These messages could:
    • Promote situational substitution of ENDS when smokers cannot smoke cigarettes, rather than complete substitution of ENDS for cigarettes.
    • Undermine clean indoor air standards, smokefree policy enforcement, and tobacco-free social norms.
  • In a randomized controlled trial, adolescents who viewed e-cigarette TV advertisements reported a significantly greater likelihood of future e-cigarette use compared with the control group. They were also more likely to agree that e-cigarettes can be used in places where smoking is not allowed.
  • Some ENDS companies are using techniques similar to those used by cigarette companies that have been shown in the 2012 Surgeon General’s Report to increase use of cigarettes by youth, including: candy-flavored products; youth-resonant themes such as rebellion, glamour, and sex; celebrity endorsements; and sports and music sponsorships.
  • Visual depictions of ENDS use in advertisements may serve as smoking cues to smokers and former smokers, increasing the urge to smoke and undermining efforts to quit or abstain from smoking.
• Given the currently available evidence on ENDS, several policy levers are appropriate to protect public health:
  • Prohibitions on marketing or sales of ENDS that result in youth use of any tobacco product, including ENDS.
    • States laws prohibiting sales of ENDS to minors that feature strong enforcement provisions and allow localities to develop more stringent policies are more likely to help prevent youth access.
  • Prohibitions on ENDS use in indoor areas where conventional smoking is not allowed could:
    • Preserve clean indoor air standards and protect bystanders from exposure to secondhand ENDS aerosol.
    • Support tobacco-free norms.
    • Support enforcement of smoke-free laws.
  • When addressing potential public health harms associated with ENDS, it is important to simultaneously uphold and accelerate strategies found by the Surgeon General to prevent and reduce combustible tobacco use, including tobacco price increases, comprehensive smoke-free laws, high-impact media campaigns, barrier-free cessation treatment and services, and comprehensive statewide tobacco control programs.

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