"The 1988 Surgeon General’s report lists the following general 'criteria for drug dependence,' including nicotine dependence (USDHHS 1988, p. 7):

"Primary Criteria
"• Highly controlled or compulsive use
"• Psychoactive effects
"• Drug-reinforced behavior

"Additional Criteria
"• Addictive behavior, often involves:
"– stereotypic patterns of use
"– use despite harmful effects
"– relapse following abstinence
"– recurrent drug cravings
"• Dependence-producing drugs often produce:
"– tolerance
"– physical dependence
"– pleasant (euphoriant) effects

"These criteria are consistent with those for a diagnosis of dependence provided in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association [APA] 2000) and the International Classification of Diseases, Tenth Revision (ICD-10) (Table 4.1) (World Health Organization [WHO] 1992). The diagnosis of dependence using these diagnostic systems depends on the person experiencing a specific number of these symptoms. The relevance of some of these symptoms to nicotine addiction may be questionable because the DSM criteria are used across different drugs of abuse. For example, one symptom of addiction is that a great deal of time is spent in activities necessary to obtain the substance or recover from its effect. This criterion may not be as relevant to the diagnosis of nicotine addiction compared with other abused substances."

"Substance use disorders (SUDs) are characterized by impairment caused by the recurrent use of alcohol or other drugs (or both), including health problems, disability, and failure to meet major responsibilities at work, school, or home. The 2021 NSDUH included a series of questions to estimate the percentage of the population aged 12 or older who had at least one SUD in the past 12 months (subsequently referred to as “an SUD” or “a past year SUD”). The SUD questions assess the presence of an SUD in the past 12 months based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).^61,62 Respondents were asked SUD questions for any alcohol or drugs they used in the 12 months prior to the survey. Drugs include marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, and any use of prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), and pain relievers.¹⁸ Unlike in the section on Illicit Drug Use in the Past Year, the DSM-5 SUD criteria for prescription drugs apply to people who used but did not misuse prescription drugs in the past year, in addition to people who misused them.

"A Clinical Validation Study (CVS) was conducted in early 2020 to assess NSDUH SUD questions that were revised to be consistent with the DSM-5 criteria discussed as follows.⁶³ For the 2021 NSDUH, the SUD questions from the CVS replaced the SUD questions in the 2020 questionnaire. Also beginning in 2021, NSDUH respondents who reported any use of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives) in the past year (i.e., not just misuse of prescription drugs) were asked the respective SUD questions for that category of prescription drugs.

"DSM-5 includes the following SUD criteria (as measured in the 2021 NSDUH):

"1. The substance is often taken in larger amounts or over a longer period than intended.

"2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

"3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

"4. There is a craving, or a strong desire or urge, to use the substance.

"5. There is recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

"6. There is continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance.

"7. Important social, occupational, or recreational activities are given up or reduced because of substance use.

"8. There is recurrent substance use in situations in which it is physically hazardous.

"9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

"10. There is a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount of the substance (i.e., tolerance).

"11. There are two components of withdrawal symptoms, either of which meet the overall criterion for withdrawal symptoms:
"a. There is a required number of withdrawal symptoms that occur when substance use is cut back or stopped following a period of prolonged use.⁶⁴
"b. The substance or a related substance is used to get over or avoid withdrawal symptoms.⁶⁵"

"Of the people who sample a particular substance, what portion will become physiologically or psychologically dependent on the drug for some period of time? Heroin and methamphetamine are the most addictive by this measure. Cocaine, pentobarbital (a fast-acting sedative), nicotine and alcohol are next, followed by marijuana and possibly caffeine. Some hallucinogens—notably LSD, mescaline and psilocybin—have little or no potential for creating dependence."

"In a large, nationally representative sample of US adults, the cumulative probability of transition to dependence was highest for nicotine users, followed by cocaine users, alcohol users and, lastly, cannabis users. The transition to cannabis or cocaine dependence occurred faster than the transition to nicotine or alcohol dependence. Furthermore, there were important variations in the probability of becoming dependent across the different racial-ethnic groups. Most predictors of transition were common across substances.

"Consistent with previous estimates from the National Comorbidity Survey (Wagner and Anthony, 2002a), the cumulative probability of transition from use to dependence a decade after use onset was 14.8% among cocaine users, 11.0% among alcohol users, and 5.9% among cannabis users. This probability was 15.6% among nicotine users. Furthermore, lifetime cumulative probability estimates indicated that 67.5% of nicotine users, 22.7% of alcohol users, 20.9% of cocaine users, and 8.9% of cannabis users would become dependent at some time in their life."

"Method: Members of the Independent Scientific Committee on Drugs, including two invited specialists, met in a 1-day interactive workshop to score 20 drugs on 16 criteria: nine related to the harms that a drug produces in the individual and seven to the harms to others. Drugs were scored out of 100 points, and the criteria were weighted to indicate their relative importance."

"Findings: MCDA [multicriteria decision analysis] modelling showed that heroin, crack cocaine, and methamphetamine were the most harmful drugs to individuals (part scores 34, 37, and 32, respectively), whereas alcohol, heroin, and crack cocaine were the most harmful to others (46, 21, and 17, respectively). Overall, alcohol was the most harmful drug (overall harm score 72), with heroin (55) and crack cocaine (54) in second and third places."

According to the Substance Abuse and Mental Health Service's Treatment Episode Data Set, in 2015 in the US there were 213,001 admissions to treatment with marijuana reported as the primary substance of abuse out of the total 1,537,025 admissions to treatment in the US for those aged 12 and older for all substances that year. This is the lowest number of marijuana admissions and total treatment admissions in at least a decade: marijuana admissions peaked in 2009 at 373,338, and total admissions peaked in 2008 at 2,074,974.

"Exposure to early life stress, even to more severe forms such as physical and sexual abuse and emotional neglect, is common in the general population. The degree of risk for adult psychopathology tends to be correlated with the severity of childhood maltreatment and the number of childhood SLE [stressful life events]. An important causal pathway that links early life stress to the onset of psychiatric disorders is the altered homeostasis in the HPA [hypothalamicpituitary-adrenal] axis and the altered stress response circuitry that underlies many disorders including anxiety, depression, PTSD, and addiction. There appears to be a direct pathway from chronic stress exposure in prepubertal children via adolescent problem drinking to alcohol and drug dependence in early adulthood that is independent of family history. Of course, this can only occur in individuals exposed to the availability of alcohol or drugs. Early life stress may increase vulnerability to addiction through permanent effects on the expression of genes within the mesolimbic dopamine reward pathway. Early onset of problem drinking in stress-exposed children may exacerbate the deleterious effects on the developing brain. Since a large proportion of stress-exposed children do not go on to develop addiction, clearly resilience factors, including gene–environment interactions, are important. This review of the literature indicates that prevention should focus on early intervention in problem families to forestall maltreatment. Adolescence is a critically vulnerable time for the development of risky drinking habits, and this is an area where prevention, through the development of positive family, peer, and neighborhood-mediating factors, is vital. A holistic approach to the treatment of alcohol and drug dependence is essential since treatment is unlikely to be effective unless underlying impediments such as early life stress are recognized and addressed."