Drug Use Estimates: Prevalence and Trends

In 2023, among people aged 12 or older in the United States:

• An estimated 47,657,000 people were past-month users of any illicit drug;
• An estimated 43,647,000 people were past-month users of marijuana or hashish;
• An estimated 1,814,000 people were past-month users of cocaine;
• An estimated 49,888,000 people were past-month users of tobacco products;
• An estimated 26,605,000 were past-month users of nicotine vaping products;
• An estimated 134,729,000 people were past-month alcohol users, of whom 61,428,000 were "binge drinkers" (binge drinking is defined as five or more drinks (for males) or four or more drinks (for females) on the same occasion on at least one day in the past 30 days), of whom 16,412,000 were "heavy" alcohol users (heavy alcohol use is defined as binge drinking on the same occasion on each of five or more days in the past 30 days).

Table: Estimated Prevalence of Past-Month Substance Use in US by People Aged 12 and Older

"Among people aged 12 or older in 2023, 70.5 million people used illicit drugs in the past year (Figure 12). The most commonly used illicit drug in the past year was marijuana, which was used by 61.8 million people. In the past year, 8.8 million people used hallucinogens, and 8.6 million people misused prescription pain relievers. Smaller numbers of people were past year users or misusers of the other illicit drugs shown in Figure 12.³³"

"Among people aged 12 or older in 2023, 47.5 percent (or 134.7 million people) drank alcohol in the past month (Figures 7 and 8 and Table A.1B). The percentage was highest among adults aged 26 or older (51.9 percent or 116.1 million people), followed by young adults aged 18 to 25 (49.6 percent or 16.9 million people). The percentage was lowest among adolescents aged 12 to 17 (6.9 percent or 1.8 million people).

"By Race/Ethnicity

"Among people aged 12 or older in 2023, 52.3 percent of White people drank alcohol in the past month (Table B.4B). This percentage was higher than the percentages of people in other racial or ethnic groups. Multiracial (46.5 percent), Black (42.5 percent), or Hispanic people (41.2 percent) had a higher estimate of past month alcohol use compared with Asian (32.5 percent) or American Indian or Alaska Native people (30.0 percent). The estimate of current alcohol use could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.¹⁵"

"We estimated nearly 3.7 million people, or 1.5% of the US adult population, injected drugs in 2018. This estimate is more than 5 times the most recent US estimate of ∼774,000 from 2011 [25]. Much of this increase is likely attributable to increases in IDU, but it is important to consider methodological differences in the creation of this 2018 estimate vs the 2011 estimate. The 2011 estimate was based on self-reported IDU among respondents to household surveys [26], but the present estimate combines available data on substance-specific overdose deaths and treatment admissions with cohort and cross-sectional data collected from known PWID. Applying the same data sources and analytic methods used for the 2018 estimate to 2011 yields an estimated 1.3 million PWID in 2011, which suggest the 2018 estimate is closer to 3 times higher than in 2011. By any measure, these estimates suggest the number of PWID has increased substantially in the U.S. during the past decade.

"One of the primary contributions of this estimate is the transparent, replicable nature of the methods described. Overdose data specifically among PWID in the United States continue to be relatively sparse, both in research and surveillance data. We used the best data currently available for each input, which are subject to limitations in some cases given data sparsity. For example, we used the meta-analyzed ratio of fatal to nonfatal overdose among PWID in OECD countries rather than a ratio specific to the United States, which was unattainable given currently available data. The uncertainty associated with this meta-analyzed ratio is reflected in confidence intervals around estimates presented here. Our intention is that, as surveillance systems implemented in the United States in recent years mature [39], resulting data can be used to refine and update this PWID population size estimate.

"Notwithstanding data input limitations, this updated estimate provides a data point for monitoring the US PWID population size over time and can inform strategies to reduce transmission of infectious diseases. In recent years, political will has been building to eliminate HCV and HIV infections in the United States [27, 28]. Both bloodborne infections disproportionately affect PWID but are highly preventable using evidence-based interventions, such as provision of sterile syringes through syringe services programs and substance use treatment [40–43], as well as treatment of prevalent infections with antiretroviral therapy [44] and direct-acting antivirals [45]. Increases in IDU prevalence will threaten the success of elimination strategies for HCV and HIV infections in the absence of concomitant increases in availability of harm reduction services and treatment for both infectious diseases and substance use. These services will need to be substantially scaled up nationally to meet the needs of nearly 4 million people [46].

"In addition to the high burden of infectious diseases, PWID experience preventable mortality and morbidity due to drug overdose. Overall, the rate of overdose deaths increased from approximately 6 per 100,000 persons to 22 per 100,000 persons during 1999–2019 [21], and provisional data indicate the number of overdose deaths increased by another 31% during just 1 year of the pandemic era from March 2020 to March 2021 [24]. During the pandemic era in particular, many questions remain about the extent to which increased overdose mortality rates are attributable to injection initiation vs changes in injection behaviors or the drug supply as well as to disruptions in access to treatment and recovery support services and harm reduction services. These estimates provide a prepandemic baseline and can improve our understanding of potential increases vs changes in pandemic-era injection behavior."

"Among people aged 12 or older in 2023, 22.7 percent (or 64.4 million people) used tobacco products or vaped nicotine in the past month (Figure 2 and Table A.1B). The percentage of people who used tobacco products or vaped nicotine in the past month was highest among young adults aged 18 to 25 (30.0 percent or 10.2 million people), followed by adults aged 26 or older (23.4 percent or 52.3 million people), then by adolescents aged 12 to 17 (7.4 percent or 1.9 million people).

"Among current nicotine product users in 2023, the use of specific nicotine products varied by age group. An estimated 74.9 percent of adolescents aged 12 to 17 who used nicotine products in the past month only vaped nicotine products compared with 47.6 percent of young adults aged 18 to 25 and only 15.7 percent of adults aged 26 or older who used nicotine products in the past month (Figure 3 and Table A.2B). In contrast, 68.2 percent of adults aged 26 or older who used nicotine products in the past month used only tobacco products compared with 19.6 percent of young adults aged 18 to 25 and 8.6 percent of adolescents aged 12 to 17 who used nicotine products in the past month."

"Among people aged 12 or older in 2023, 70.5 million people used illicit drugs in the past year (Figure 12). The most commonly used illicit drug in the past year was marijuana, which was used by 61.8 million people. In the past year, 8.8 million people used hallucinogens, and 8.6 million people misused prescription pain relievers. Smaller numbers of people were past year users or misusers of the other illicit drugs shown in Figure 12.³³

"Any Illicit Drug Use

"Among people aged 12 or older in 2023, 24.9 percent (or 70.5 million people) used illicit drugs in the past year (Figures 12 and 13 and Table A.5B). The percentage was highest among young adults aged 18 to 25 (39.0 percent or 13.3 million people), followed by adults aged 26 or older (23.9 percent or 53.5 million people), then by adolescents aged 12 to 17 (14.7 percent or 3.8 million people).

"By Race/Ethnicity

"The percentage of people aged 12 or older in 2023 who used illicit drugs in the past year was higher among American Indian or Alaska Native (36.7 percent) or Multiracial people (36.2 percent) than among White (26.1 percent), Hispanic (21.6 percent), or Asian people (12.4 percent) (Figure 14 and Table B.8B). The percentage also was higher among Multiracial people than among Black people (27.7 percent). Black or White people were more likely to have used illicit drugs in the past year compared with Hispanic people.

"Asian people were less likely to have used illicit drugs in the past year compared with people in other racial or ethnic groups. Estimates for illicit drug use in the past year did not differ significantly among Black or White people. The estimate of illicit drug use in the past year could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.¹⁵"

"Between 2019 and 2021, the prevalence of chronic pain among U.S. adults ranged from 20.5% to 21.8%, and the prevalence of high-impact chronic pain ranged from 6.9% to 7.8% (Figure). During 2021, an estimated 51.6 million U.S. adults (20.9%) experienced chronic pain, and 17.1 million (6.9%) experienced high-impact chronic pain (Table). The age-adjusted prevalence of both chronic pain and high-impact chronic pain was notably higher among certain demographic population groups including AI/AN adults, adults identifying as bisexual, and adults who were divorced or separated. The age-adjusted prevalence of high-impact chronic pain among AI/AN adults (12.8%) was six times as high as among nonHispanic Asian adults (2.1%) and nearly twice as high as among non-Hispanic White adults (6.5%). The age-adjusted prevalence of chronic pain among adults identifying as bisexual was 32.9%, compared with 19.3% among adults identifying as straight and 20.7% among those identifying as gay or lesbian. The age-adjusted prevalence of chronic pain and high-impact chronic pain among adults who were divorced or separated (29.6% and 10.1%, respectively) was nearly twice as high as among those who were married (18.2% and 5.2%, respectively). The age-adjusted prevalence of chronic pain and high-impact chronic pain among those born in the United States (21.6% and 7.0%, respectively) was nearly twice as high as among those born outside the United States (11.9% and 4.1%, respectively)."

"Alcohol use, marijuana use, and nicotine vaping all decreased in 2024 in 12th grade, in 10th grade, and in 8th grade.

"For alcohol, significant decreases in 12th and 10th grade continued a long standing decline that began in the late 1990s, more than two decades ago. The percentage of students who used any alcohol in the past 12 months in 2024 was 42% in 12th grade (compared to 75% in 1997), 26% in 10th grade (compared to 65% in 1997), and 13% in 8th grade (compared to 46% in 1997). These declines are evident in specific survey questions that ask about use of beer, wine, and liquor.

"For marijuana, decreases in use among students are a more recent development. In all grades, the percentage that used marijuana in the past 12 months hovered within a tight window of just a few percentage points in the twenty years from 2000 to 2020. The results in 2021, the first year measured after the pandemic onset, showed that large and substantial declines in marijuana use took place in all grades. In 12th and 10th grades, these declines have since continued, and past 12- month use levels in 2024 were the lowest in the past three decades, at 26% and 16%, respectively. In 8th grade, the percentage in 2024 was 7%, where it has stayed for the past four years after dropping from a pre-pandemic level of 11% in 2020.

"For nicotine vaping, the 2024 declines continue a 180-degree turn centered around the pandemic onset. Prior to the pandemic, use levels surged from 2017 to 2019 and then held steady in 2020. Large declines took place during the pandemic and have since continued to the point where the 2024 levels for past 12-month use are close to where they started in 2017, the first year that questions on nicotine vaping were included on the survey. Specifically, past 12-month use was 21% in 12th grade (compared to 35% in 2020 and 19% in 2017), 15% in 10th grade (compared to 31% in 2020 and 16% in 2017), and 10% in 8th grade (compared to 17% in 2020 and 10% in 2017)."

"Among people aged 12 or older in 2023, 0.3 percent (or 828,000 people) misused fentanyl in the past year, including 0.2 percent of adolescents aged 12 to 17, 0.3 percent of young adults aged 18 to 25, and 0.3 percent of adults aged 26 or older (Table A.12B). Corresponding estimated numbers of people who misused fentanyl in the past year were 50,000 adolescents aged 12 to 17, 110,000 young adults aged 18 to 25, and 668,000 adults aged 26 or older.

"Among people in 2023 who misused any prescription pain reliever in the past year, only 7.4 percent misused fentanyl. Among people who used fentanyl for any reason in the past year, 28.6 percent misused it and 71.4 percent did not.24

"IMF [Illegally Made Fentanyl] Use

"Because people who used IMF may have been unaware that they used it, caution must be taken in interpreting estimates of IMF use; these estimates are almost certainly an underestimate of true IMF use.

"Among people aged 12 or older in 2023, 0.2 percent (or 627,000 people) used IMF in the past year, including 0.1 percent of adolescents aged 12 to 17, 0.2 percent of young adults aged 18 to 25, and 0.2 percent of adults aged 26 or older (Table A.12B). Corresponding estimated numbers of people who used IMF in the past year were 36,000 adolescents aged 12 to 17, 78,000 young adults aged 18 to 25, and 513,000 adults aged 26 or older."

"Abstention from drug use is defined here as no past 30-day use of alcohol, marijuana, or nicotine by vaping or by cigarettes. Abstention levels in 2024 were at the highest recorded by the survey since it first started tracking this outcome in 2017. The percentage of students who abstained from drug use in 2024 was 67% in 12th grade (compared to 53% in 2017), 80% in 10th grade (compared to 69% in 2017), and 90% in 8th grade (compared to 87% in 2017). The increases from 2023 to 2024 were statistically significant in 12th and 10th grade.

"Whether the lowered levels of drug use after the pandemic would be long lasting has been a question with substantial policy and research implications. It is possible that the factors that disrupted and lowered drug use during the pandemic from 2020 to 2021 resulted in permanent change. This could occur if the pandemic disrupted both school/community peer groups that encourage drug use as well as the processes by which these groups perpetuate themselves by recruiting new members. Alternatively, substance use could have quickly rebounded to pre-pandemic levels when students returned to school buildings in 2022 and afterwards, if prepandemic patterns of social interaction and drug use rapidly re-established. The 2024 results indicate that the lowered levels of student drug use after the pandemic onset are lasting and, in fact, continue to drop even further."

"In 2023, 22% of high school students drank alcohol during the past 30 days. Female students were more likely than male students to currently drink alcohol. Asian and Black students were less likely than Hispanic, White, and Multiracial students to currently drink alcohol. LGBTQ+ students were more likely than cisgender and heterosexual students to currently drink alcohol."

"In 2023, 17% of high school students used marijuana during the past 30 days. Female students were more likely than male students to currently use marijuana. Asian students were less likely than students from most other racial and ethnic groups to currently use marijuana. LGBTQ+ students were more likely than cisgender and heterosexual students to currently use marijuana."

"In 2023, 10% of high school students had ever used certain illicit drugs (defined as cocaine, inhalants, heroin, methamphetamines, hallucinogens, or ecstasy). Black students were less likely than American Indian or Alaska Native, White, and Multiracial students to have ever used select illicit drugs. LGBTQ+ students were more likely than cisgender and heterosexual students to have ever used select illicit drugs."

"In 2023, 12% of high school students had ever misused prescription opioids, defined as taking prescription pain medicine, such as codeine, Vicodin, OxyContin, Hydrocodone, or Percocet, without a doctor’s prescription or differently than how a doctor told them to use it. Female students were more likely than male students to have ever misused prescription opioids. White students were less likely than Black, Hispanic, and Multiracial students to have ever misused prescription opioids. LGBTQ+ students were more likely than cisgender and heterosexual students to have ever misused prescription opioids."

"Globally, 1.03 billion (95% UI 0·851–1·19) males (35.1% [29.1–40.7] of the male population aged ≥15 years) and 312 million (199–432) females (10.5% [6.72–14.6] of the female population aged ≥15 years) consumed alcohol in amounts exceeding the NDE [Non-Drinker Equivalence] in 2020; the number and proportion of people consuming alcohol in excess of the NDE, along with the percentage change since 1990 in the proportion of people consuming alcohol in excess of the NDE, by age group, sex, and location is reported in table 1. Since 1990, the global proportion of drinkers consuming alcohol in excess of the NDE has not changed significantly. Although the proportion of the population consuming harmful amounts of alcohol stayed at the same level over the past three decades, the number of people consuming harmful amounts of alcohol increased from 983 million (718–1190) in 1990 to 1.34 billion (1.06–1.62) in 2020, driven by population growth. Overall, among individuals consuming harmful amounts of alcohol in 2020, 76.9% (73.0–81.3) were male."

"Use of hallucinogens in the past 12 months was similar for college and noncollege young adults (7.5% vs. 10.8%) in 2023. There were also no significant differences for past 12 month use of LSD (1.8% vs. 2.3%), hallucinogens other than LSD (7.4% vs. 10.4%), MDMA (ecstasy, Molly; 0.3% vs. 1.2%), and ketamine (1.8% vs. 0.9%; Table/Figure 96)."

"• The majority of 12th graders disapprove of regular use of any of the illicit drugs (see Table 8-6). Among 12th graders in 2023, more than 90% disapprove of regular use of each of them.

"• For each of the drugs included in this set of questions, fewer respondents indicate disapproval of experimental or occasional use than of regular use, as might be expected. However, the differences are not great for the use of illicit drugs other than marijuana, because nearly all 12th graders disapprove of even experimenting with them. For example, in 2023 the proportions disapproving of experimental use are 92% for heroin, 91% for cocaine, 73% for LSD, and 86% for MDMA (ecstasy, Molly). The high levels of disapproval could be widely publicized and provide the basis for some potentially powerful prevention messages in the form of normative education.

"• Disapproval of marijuana by 12th graders increases substantially for more regular levels of use. In 2023 the percentage who disapprove of marijuana use is 35% for trying it once or twice, 40% for occasional use, and 60% for regular use. Looked at another way, four out of ten 12th graders (40%) say they do not disapprove of regular marijuana use.

"• Smoking a pack (or more) of cigarettes per day now meets with disapproval by almost eight out of nine (87%) 12th grade students—a level comparable to the level of disapproval for many of the illicit drugs and substantially higher than disapproval of regular marijuana use.

"• The lowest levels of disapproval for regular use among 12th grade students in 2023 are regular marijuana use at 60%, regular marijuana vaping at 69%, daily alcohol drinking at 72%, and regular nicotine vaping at 80%. Regular marijuana vaping has a substantially lower level of disapproval than does regular nicotine vaping.

"• Having one or two drinks nearly every day meets with the disapproval of 72% of 12th graders in 2023. Curiously, fewer 12th graders (66%) disapprove of weekend binge drinking (five or more drinks once or twice each weekend), despite the fact that more of them see a great risk in weekend binge drinking (39%) than in having one or two drinks nearly every day (24%). This divergence between the perceived risk associated with the two behaviors and the corresponding levels of disapproval helps to illustrate their differences."

Table: Estimated Prevalence of Daily Use of Various Drugs By US Youth In Grades 8, 10, and 12 Combined

Table: Annual Prevalence of Use of Various Drugs by US Youth in Grades 8, 10, and 12 Combined

"Globally, there are nearly 15.6 million people (aged 15–64) who inject drugs (PWID), with an estimated 2.6 million PWID in North America (Degenhardt et al., 2017). Canada and the United States (US) have both seen significant increases in the rate of injection drug use, as well as a rise in the rate of infections and fatal overdose related to injection drug use (Jacka et al., 2020; Levitt et al., 2020). The risk of fatal overdose significantly increases when people inject drugs alone, and may be prevented with timely intervention (i.e. administration of naloxone, an overdose prevention medication) (Colledge et al., 2019). There is also an increased risk of disease transmission (e.g. HIV, hepatitis) and serious infections associated with injecting drugs, which are often related to using unsterile equipment, injecting in unhygienic settings, or rushed injections (Colledge et al., 2019). The increase in injection drug use and the risks associated with using alone, in unhygienic or unsupervised settings necessitate the need for services that support safe injection practices among PWID."

The National Survey on Drug Use and Health is conducted annually by the Substance Abuse and Mental Health Services Administration. According to the NSDUH, in 2022:

• 143,116,000 people in the US aged 12 or older had used an illegal drug or marijuana in their lifetimes;
• 70,338,000 people in the US aged 12 or older had used an illegal drug or marijuana in the past year;
• 46,603,000 people in the US aged 12 or older had used an illegal drug or marijuana in the past month.

In 2021:

• 139,677,000 people in the US aged 12 and older had used an illegal drug or marijuana in their lifetimes;
• 61,995,000 people in the US aged 12 or older had used an illegal drug or marijuana in the past year;
• 40,564,000 people in the US aged 12 or older had used an illegal drug or marijuana in the past month.

NSDUH also reported that in 2022:

• 132,296,000 people in the US aged 12 or older had used marijuana in their lifetimes;
• 61,901,000 people in the US aged 12 or older had used marijuana in the past year;
• 42,317,000 people in the US aged 12 or older had used marijuana in the past month.

In 2021:

• 128,961,000 people in the US aged 12 or older had used marijuana in their lifetimes;
• 53,181,000 people in the US aged 12 or older had used marijuana in the past year;
• 36,950,000 people in the US aged 12 or older had used marijuana in the past month.

Table: Marijuana Use and Illegal Drug Use: Lifetime, Past Year, and Past Month Use by People in the US Aged 12 and Over

Table: Estimated Prevalence of Monthly Use of Various Drugs by US Eighth Graders in the US

"Among people aged 12 or older in 2022, 5.7 percent (or 16.1 million people) were heavy alcohol users in the past month (Figures 8 and 9 and Table A.1B). The percentage was highest among young adults aged 18 to 25 (7.6 percent or 2.6 million people), followed by adults aged 26 or older (6.0 percent or 13.4 million people). The percentage was lowest among adolescents aged 12 to 17 (0.2 percent or 63,000 people).

"By Race/Ethnicity

"Among people aged 12 or older in 2022, White people were more likely to be heavy alcohol users in the past month (6.6 percent) compared with Hispanic (5.1 percent), Black (4.2 percent), or Asian people (1.9 percent) (Figure 11 and Table B.4B). Asian people were less likely to be heavy alcohol users in the past month compared with people in other racial or ethnic groups. The estimate of current heavy alcohol use could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.13"

"In 2019, relatively low rates of xylazine NFLIS [National Forensic Laboratory Information System] reports were observed; all states had a rate below 6 xylazine NFLIS reports per 100,000 residents, and 16 states had zero NFLIS xylazine reports (Figure 1; eTable 4 in Supplement 1). In contrast, in 2022, only 2 states had zero xylazine NFLIS drug reports, and the highest rates of xylazine NFLIS reports (per 100,000 residents) were observed in New Jersey (30.52), Rhode Island (22.82), Maryland (18.91), Virginia (15.47), New Hampshire (13.10), and Ohio (10.87). In 2019, xylazine NFLIS reports were limited to a few northeastern states; by 2022, xylazine NFLIS reports were still concentrated in northeastern states yet had extended to states south and west.

"In 2022, xylazine represented 16.17% of all NFLIS reports in Delaware and between 5.95% and 7.00% of NFLIS reports in Connecticut, Maryland, DC, New Jersey, and Rhode Island, yet less than 1.00% of NFLIS reports in 35 different states (Figure 2; eTable 5 in Supplement 1). Delaware, Maryland, Rhode Island, New Jersey, Connecticut, DC, and Virginia had the highest absolute change in xylazine reports as a percentage of all NFLIS drug reports (2019-2022), while Virginia, Maryland, North Carolina, Michigan, Kansas, Alabama, Minnesota, and Tennessee had the highest relative change. Only 1 state, Wisconsin, recorded a decrease in xylazine’s representation in NFLIS drug reports from 2019 (0.56% of drug reports) to 2022 (0.48% of drug reports), and 2 states reported no increase (0% in 2019 to 0% in 2022; South Dakota and Wyoming) yet in 30 states, across all regions, xylazine reports (as a percentage of all NFLIS drug reports) more than doubled."

"Steroids

"In 2023 lifetime prevalence of anabolic steroid use was 1% in all grades. In general, lifetime, past 12-month, and past 30-day use have decreased, sometimes unevenly, since highs in the early 2000s.

"Anabolic steroids, sometimes used for muscle development including in body building, were rendered illegal to purchase or sell without a prescription in the Anabolic Steroids Control Act of 1990. Prevalence of use fell among 12th graders for a couple of years thereafter, but then increased some. Use for all grades peaked around 2002 and have since declined substantially.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns.

"Creatine

"Creatine is not a hormone or a drug but a nutrient found in the skeletal muscle of most animals. It is used to reduce the recovery time of muscles, to increase muscle mass, and to thereby enhance performance for high-intensity, short-duration exercises. It is readily available over the counter, which undoubtedly helps to explain the substantial levels of use we have found among teens.

"Past 12-month use maintained the large increases that took place last year, from 2021 to 2022. All grades levels are at the highest recorded since the project first began tracking use of this substance in 2001. Prevalence in 2023 was 12% in 12th grade, 11% in 10th grade, and 5% in 8th grade.

"These results are consistent with the possibility of an increase in the proportion of adolescents involved in fitness and weightlifting during the pandemic. Lasting increases since 2021 also took place for the performance-enhancing drug androstenedione, which is sometimes used with creatine.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns.

"Androstenedione

"Androstenedione, a precursor to testosterone, is a performance-enhancing substance that was scheduled by the Drug Enforcement Administration early in 2005, making its sale and possession no longer legal.

"In 12th grade, past 12-month prevalence was 1.4% in 2023, and maintained most of the large increase that took place last year, when it jumped to 1.9% in 2022 from 0.6% in 2021. The current higher levels in 2023 are a departure from the long-term decline that started at 3.0% in 2001 and decreased to 0.5% by 2019.

"These results are consistent with the possibility of a lasting increase in the proportion of 12th grade students involved in fitness and weightlifting during the pandemic. Lasting increases also took place since 2021 for the performance-enhancing drug of creatine.

"The survey stopped tracking this drug among 8th and 10th graders after 2014, when prevalence levels were less than 1% in these grades.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns."

"Among people aged 12 or older in 2022, 21.7 percent (or 61.2 million people) were binge drinkers in the past month (Figures 8 and 9 and Table A.1B). The percentage was highest among young adults aged 18 to 25 (29.5 percent or 10.3 million people), followed by adults aged 26 or older (22.6 percent or 50.1 million people). The percentage was  lowest among adolescents aged 12 to 17 (3.2 percent or 834,000 people).

"By Race/Ethnicity

"Among people aged 12 or older in 2022, Asian people (10.3 percent) were less likely to be binge drinkers in the past month compared with people in other racial or ethnic groups (Figure 10 and Table B.4B). The estimate of binge drinking in the past month could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.13 Estimates of binge drinking in the past month did not differ significantly among people in the other racial or ethnic groups."

"Prevalence of past-12 month ketamine use among 12th grade students has been below 2% for the past decade and in 2023 stood at 1%. This 'club drug' was added to the survey in 2000. It showed little change in its usage levels through 2002. Since then use has declined in all grades. Because of the very low levels of use of this drug by 2011, questions about its use were dropped from the questionnaires administered to 8th and 10th graders."

"In 2022, 48.7 million people aged 12 or older (or 17.3 percent of the population) had an SUD in the past year, including 29.5 million who had an alcohol use disorder and 27.2 million who had a drug use disorder (Figures 31, 32, and 33 and Tables A.16B and A.17AB). Among the 29.5 million people with a past year alcohol use disorder, 21.5 million had an alcohol use disorder but not a drug use disorder. Among the 27.2 million people with a past year drug use disorder, 19.2 million had a drug use disorder but not an alcohol use disorder. Among people with a past year SUD, 16.5 percent (or 8.0 million people) had both an alcohol use disorder and a drug use disorder in the past year.

"The percentage of people in 2022 with a past year SUD differed by age group. The percentage was highest among young adults aged 18 to 25 (27.8 percent or 9.7 million people), followed by adults aged 26 or older (16.6 percent or 36.8 million people), then by adolescents aged 12 to 17 (8.7 percent or 2.2 million people) (Figure 33 and Table A.16B).

"By Race/Ethnicity

"Percentages of people aged 12 or older in 2022 with a past year SUD ranged from 9.0 percent of Asian people to 24.0 percent of American Indian or Alaska Native people (Figure 34 and Table B.14B). Except for Asian people, percentages did not differ significantly by race or ethnicity. The percentage of Asian people aged 12 or older in 2022 with a past year SUD was lower than the percentages among people in most other racial or ethnic groups. The percentage of people aged 12 or older in 2022 with a past year SUD could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.¹³"

"• Perceived availability differs substantially across drugs (Tables 9-10 to 9-12). In 2023 the percentage of 12th graders reporting it would be fairly easy or easy to get a drug varied from 12% or less for heroin, crack, and crystal methamphetamines to 73% and above for alcohol, vaping devices, and marijuana.

"• In general, the more widely used drugs are reported to be available by higher proportions of the age group, as would be expected. The substances with the highest levels of use in 2023, specifically marijuana, alcohol, and vaping devices, also place in the top three in terms of perceived availability.

"• Older adolescents generally perceive drugs to be more available. For example, in 2023, 26% of 8th graders said marijuana would be fairly easy or very easy to get (which we refer to as “readily available”), versus 48% of 10th graders and 73% of 12th graders.

"• Higher availability among both the more widely used drugs and also older age groups is consistent with the notion that availability is largely attained through friendship circles. (Friends clearly are the leading source through which 12th graders obtain prescription drugs, as discussed above.) The differences among age groups may also reflect less willingness and/or motivation on the part of those who deal drugs to establish contact with younger adolescents.

"• Marijuana appears to be readily available to the great majority of 12th graders; in 2023, 73% reported that they think it would be very easy or fairly easy to get—far higher than the proportion who reported ever having used it (37%).

"• There is a considerable drop in availability after marijuana, alcohol, cigarettes, and vaping; the next most readily available class of drugs for 12th graders is amphetamines, with 31% saying these drugs would be very or fairly easy to get, followed by hallucinogens other than LSD (31%, such as psychedelic mushrooms or peyote).

"• Substances with the lowest availability among 12th grade students in 2023 are crystal methamphetamine (8%), crack (12%), heroin (12%), cocaine powder (12%), and steroids (17%).

"• In each grade similar percentages of students reported they could fairly or very easily get a vaping device, e-liquids with nicotine, or flavored vaping solutions. In 8th grade the percentage were, respectively, 34%, 32%, and 30%. In 10th grade they were 55%, 52%, and 51%. In 12th grade they were 76%, 73%, and 72%.

"• In 2023, 33% of 8th graders, 48% of 10th graders, and 60% of 12th graders thought that cigarettes would be fairly easy or very easy for them to get if they wanted some.

"• Alcohol has the highest level of availability in each grade. The percentage saying it would be fairly easy or very easy to get in 8th grade was 41%, in 10th grade was 59%, and in 12th grade was 82%.

"• Drug availability levels are lowest in 8th grade. Even so, in 2023 marijuana was reported as readily available by about one in four (26%) 8th grade students.

"• Because many inhalants—such as glues, butane, and aerosols—are universally available, we do not ask about their availability. See Table 9-12 for the full list of drugs included in the questions for 12th graders; a few of these drugs were not asked of the younger students (see Tables 9-10 and 9-11)."

"The prevalence of lifetime substance use among adolescents in 2018 was 26.3% (95% CI, 25.4-27.2) for alcohol, 15.4% (95% CI, 14.7-16.1) for cannabis, and 13.4% (95% CI, 12.7-14.1) for tobacco; among young adults in 2018, prevalence of lifetime substance use was 79.7% (95% CI, 78.9- 80.5) for alcohol, 51.5% (95% CI, 50.4-52.6) for cannabis, and 5.0% (95% CI, 53.9-56.1) for tobacco. Prevalence of SUDs differed by substance, age group, and time since initiation. Adjusted prevalence of cannabis use disorder was higher among adolescents than among young adults within 12 months of initiation (10.7%; 95% CI, 9.3-12.3 vs. 6.4%; 95% CI, 5.2-7.9) and at more than 36 months (20.1% [95% CI, 18.0-22.3] vs. 10.9% [95% CI, 10.3-11.4]) (Table). Prevalence of alcohol use disorder and nicotine dependence did not differ between the 2 groups within 12 months of initiation but was higher for young adults in subsequent periods.

"Among young adults, prevalence of lifetime cocaine, methamphetamine, and heroin use in 2018 was 11.4% (95% CI, 10.7-12.1), 2.5% (95% CI, 2.2-2.8), and 1.3% (95% CI, 1.1-1.5), respectively. Within 12 months of initiation, adjusted prevalence was higher for methamphetamine use disorder (24.8% [95% CI, 16.8-34.9]) and heroin use disorder (30.9% [95% CI, 20.6-43.4]) than for cocaine use disorder (5.6% [95% CI, 4.2-7.4]). Estimates for adolescents were not reported owing to limited samples.

"Prevalence of lifetime misuse of prescription drugs in 2014 was 9.2% (95% CI, 8.7-9.7) among adolescents and 26.3% (95% CI, 25.4-27.2) among young adults. Among the population with lifetime misuse, adjusted prevalence of prescription opioid use disorder, prescription stimulant use disorder, and prescription tranquilizer use disorder were consistently higher for adolescents than for young adults (Figure). Prevalence since time of initiation for adolescents was stable for prescription opioid use disorder and decreased for prescription stimulant use disorder and prescription tranquilizer use disorder, whereas for young adults, prevalence increased for prescription opioid use disorder and was stable for prescription stimulant use disorder and prescription tranquilizer use disorder."

"The 2022 NSDUH assessed the use and misuse of psychotherapeutic drugs currently or recently available by prescription in the United States, including prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), and pain relievers. In NSDUH, misuse of prescription drugs was defined as use in any way not directed by a doctor, including use without a prescription of one’s own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Misuse of over-the-counter (OTC) drugs was not included.

"Among people aged 12 or older in 2022, 5.0 percent (or 14.2 million people) misused prescription psychotherapeutic drugs in the past year (Table A.5B). The percentage was highest among young adults aged 18 to 25 (7.3 percent or 2.5 million people), followed by adults aged 26 or older (5.0 percent or 11.0 million people), then by adolescents aged 12 to 17 (2.5 percent or 640,000 people).

"Of the prescription drugs presented in this report, prescription pain relievers were the most commonly misused prescription drug by people aged 12 or older. The 14.2 million people in 2022 who misused prescription psychotherapeutic drugs in the past year included 8.5 million people who misused prescription pain relievers, 4.8 million people who misused prescription tranquilizers or sedatives (including 3.7 million past year misusers of benzodiazepines7), and 4.3 million people who misused prescription stimulants (Figure 13)."

"• In 2023 46% of 12th grade students favored legalization of marijuana (Table 8-8). Support for legalization has been steadily and rapidly increasing since 2007, when it was near 30%. Prior to 2008, support followed a U-shape curve, in which support levels near 30% were present at the beginning of the survey, in 1975, then dipped by half to a nadir of 15% in 1986–1988, only to redouble and return to around 30% by 1995, where it hovered for a decade before rising to a majority for the first time in 2019. The percentage support was 51% in 2019, 2021, and also 2022. This consistency indicates that a change in question text in 2022 did not result in a major shift in prevalence in 2022, when students were asked 'do you favor' instead of the wording 'would you favor' that was used in all previous years.

"• The proportion of 12th grade students who favor treating marijuana use as a crime in 2023 was just 7%, which ties with the previous year for the lowest level ever recorded by the survey. Trends for this outcome are a mirror image of the pattern seen for support of marijuana legalization. Back around 1990 as many as 50% thought its use should be a crime. Support has dropped by 1% to 2% in every year since 2012. The same levels of 7% in 2021, 2022, and 2023 suggest no major changes resulted from the change in question text in 2022, when students were asked 'do you favor' instead of the wording 'would you favor' that was used in all previous years.

"• Given higher levels of support for legalization among adults,18 tolerance for legalization appears to increase after the high school years.

"Past editions of this monograph reported trends in 12th grade responses to the question 'If it were legal for people to USE marijuana, should it also be legal to SELL marijuana?' and also a question on whether students would be more inclined to use marijuana if it were legalized. These questions were discontinued in 2022 in response to the changing landscape of the legal status of marijuana use across the US."

"DSM-5 includes the following SUD criteria (as measured in the 2022 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. For substances other than hallucinogens and inhalants that have a withdrawal criterion, 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

"Table 1 shows how these 11 DSM-5 SUD criteria apply to substances in NSDUH. For prescription pain relievers, tranquilizers, stimulants, and sedatives, Table 1 also shows how these criteria apply if respondents misused prescription drugs or if they simply used but did not misuse prescription drugs in the past year. For consistency with the DSM-5 criteria, NSDUH respondents were classified as having an SUD in the past year if they met two or more of the applicable criteria in the 12-month period before the interview.

"For alcohol, marijuana, cocaine, heroin, and methamphetamine in Table 1, respondents were classified as having an SUD in the past year if they met 2 or more of the 11 criteria in the 12-month period before the interview. However, respondents were classified as having a hallucinogen use disorder or an inhalant use disorder if they met 2 or more of the first 10 criteria in the past 12 months; the withdrawal criterion does not apply to hallucinogens and inhalants.

For the use or misuse of prescription drugs in Table 1, the number of applicable DSM-5 criteria for classifying respondents as having a prescription drug use disorder depends on whether respondents misused prescription drugs, or they used prescription drugs in the past year, but they did not misuse them. If respondents misused prescription drugs in the past year, they were classified as having a prescription drug use disorder if they met 2 or more of the 11 criteria shown in Table 1. However, if respondents used prescription drugs in the past year but did not misuse them, they were classified as having a prescription drug use disorder if they met two or more of the first nine criteria shown in Table 1. Criteria 10 (tolerance) and 11 (withdrawal) do not apply to respondents who used but did not misuse these prescription drugs in the past year; tolerance and withdrawal can occur as normal physiological adaptations when people use these prescription drugs appropriately under medical supervision.⁶⁶"

"In 2018, an estimated 269 million people worldwide had used drugs at least once in the previous year (range: 166 million to 373 million). This corresponds to 5.4 per cent of the global population aged 15–64 (range: 3.3 to7.5 per cent), representing nearly 1 in every 19 people.

"Over the period 2009–2018, the estimated number of past-year users of any drug globally increased from 210 million (range: 149 million to 272 million) to 269 million (range: 166 million to 373 million) – in other words, by more than a quarter (28 per cent) – partly as a result of growth in the global population. Consequently, the prevalence of drug use increased by over 12 per cent, from 4.8 per cent (range: 3.4 to 6.2 per cent) of the adult population in 2009 to 5.4 per cent (range: 3.3 to 7.5 per cent) in 2018. However, considering the wide uncertainty intervals of these estimates and that in any given year the global estimates represent the best available data, any comparison of the estimates over time should be undertaken with caution."

"The percentage of youth who have used marijuana in the past 12 months did not return to 2020 levels in 2022. Lifetime and past 12-month prevalence stayed steady or edged slightly upward in 2021, and prevalence in 2022 remained closer to 2021 than 2020 levels. Lifetime prevalence in 2022 was 11% in 8th grade, 24% in 10th grade, and 38% in 12th grade.

"The lower prevalence levels in 2021 and 2022 mark the first substantial change in past 12-month marijuana prevalence in more than a decade; previous to 2021 marijuana levels had hovered without any systematic trending for about a decade.

"Levels of annual marijuana use today are considerably lower than the historic highs observed in the late 1970s, when more than half of 12th graders had used marijuana in the past 12 months. This high point marked the pinnacle of a rise in marijuana use from relatively negligible levels before the 1960s.

"Daily marijuana use, defined as use on 20 or more occasions in the past 30 days, held steady in 2022 after substantial declines in 2021. In all grades 2022 levels remained below those in 2019 and 2020, when all surveys were collected before the start of the national social distancing policies on March 15, 2020.

"The prevalence of using marijuana daily for a month or more during one's lifetime is reported for 12th graders only. That prevalence was at 21% when first measured in 1982, declined sharply to just 8% by 1992, and rose back to 19% by 1997, followed by a long gradual decline to 12% by 2018, before leveling. It stood at 14% in 2022.

"2020 prevalence levels are not reported for daily marijuana use for a month due to low sample size that resulted from curtailed data collection due to the pandemic.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns."

"Overall, supply reduction—that is, reducing the availability of drugs—does not appear to have played as major a role as many had assumed for a number of the most important downturns in illicit drug use that have occurred to date, namely, those for marijuana, cocaine, crack, and MDMA (ecstasy, Molly) (see, for example, Figures 8-4, 8-5, and 8-6). The case of cocaine is particularly striking, as perceived availability actually rose during much of the period of downturn in use that began in the mid 1980s. (These data are corroborated by data from the Drug Enforcement Administration on trends in the price and purity of cocaine on the streets.10) For marijuana, perceived availability has remained very high for 12th graders since 1976, while use dropped substantially from 1979 through 1992 and has fluctuated considerably thereafter. Perceived availability for MDMA did increase in parallel with increasing use in the 1990s, but the decline phase for use appears to have been driven much more by changing beliefs about the dangers of ecstasy than by any sharp downturn in availability. Similarly, amphetamine use declined appreciably from 1981 to 1992, with only a modest corresponding change in perceived availability. Finally, until 1995, heroin use had not risen among 12th graders even though availability had increased substantially.

"• What did change dramatically were young peoples’ beliefs about the dangers of using marijuana, cocaine, crack, and MDMA (ecstasy, and later Molly). We believe that increases in perceived risk led to a decrease in use directly through their impact on young people’s demand for these drugs and indirectly through their impact on personal disapproval and, subsequently, peer norms. Because the perceived risk of amphetamine use was changing little when amphetamine use was declining substantially (1981–1986), other factors must have helped to account for the decline in demand for that class of drugs—quite conceivably some displacement by cocaine. Because three classes of drugs (marijuana, cocaine, and amphetamines) have shown different patterns of change, it is highly unlikely that a general factor (e.g., a broad shift in attitudes about drug use in general) can explain their various trends.

"• The increase in marijuana use in the 1990s among 12th graders added more compelling evidence to this interpretation. It was both preceded and accompanied by a decrease in perceived risk. (Between 1991 and 1997, the perceived risk of regular marijuana use declined 21 percentage points.) Perceived peer disapproval dropped sharply from 1993 through 1997, after perceived risk began to change, consistent with our interpretation that perceived risk can be an important determinant of disapproval as well as of use. Perceived availability remained fairly constant from 1991 to 1993 and then increased seven percentage points through 1998.11

"• We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion, such as snorting and smoking. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self reported heroin users are now using by means other than injection, lends credibility to this interpretation. The dramatic decline in LSD use in the early to mid 2000s is also not explainable by means of concurrent changes in perceived risk or disapproval; but availability did decline sharply during this period and very likely played a key role in reducing the use of that drug. 

"We should also note that other factors, such as price, could play an important role for some drugs. Analyses of MTF data have shown, for example, that price probably played an important role in the decline of marijuana use in the 1980s, and in changes in cigarette use in the 1990s.12,13 However, price does not appear to have the same influence in all periods for all drugs, as the dramatic reduction in cocaine prevalence during the late 1980s took place at the same time that the price of cocaine decreased,14 contrary to the supply/demand model."

"Among people aged 12 or older in 2022, 0.4 percent (or 1.0 million people) used heroin in the past year (Figures 13 and 18 and Table A.5B). The percentage was highest among adults aged 26 or older (0.4 percent or 991,000 people), followed by young adults aged 18 to 25 (0.2 percent or 55,000 people), then by adolescents aged 12 to 17 (less than 0.05 percent or 3,000 people)."

"Of the estimated 585,000 deaths attributed to drug use in 2017, half are attributed to liver cancer, cirrhosis and other chronic liver diseases related to hepatitis C, which remains mostly untreated among PWID. Deaths attributed to drug use disorders (167,000) account for 28 per cent of all deaths resulting from drug use; 110,000 or 66 per cent of those deaths are attributable to opioids. Over the past decade, the total number of deaths attributed to drug use has increased by a quarter, with a major increase in deaths caused by opioid use disorders (71 per cent increase), followed by cirrhosis and other chronic liver diseases (55 per cent increase) and liver cancer (46 per cent) resulting from hepatitis C.

"The comparison of deaths attributed to drug use among men and women over the past decade shows that the number of deaths attributed to drug use disorders, in particular opioid use disorders, has increased disproportionately among women, with a 92 per cent increase in deaths attributed to opioid use disorders among women compared with a 63 per cent increase among men."

"Consistent with the results of previous researchers,² there was no evidence that the legalization of medical marijuana encourages marijuana use among youth. Moreover, the estimates reported in the Table showed that marijuana use among youth may actually decline after legalization for recreational purposes. This latter result is consistent with findings by Dilley et al⁴ and with the argument that it is more difficult for teenagers to obtain marijuana as drug dealers are replaced by licensed dispensaries that require proof of age.⁶"

" Annual marijuana use differs little by race/ethnicity and across the three groups varies between 7% and 8% in 8th grade, 13% and 19% in 10th grade, and 26% and 33% in 12th grade.

" Both 30-day use of any illicit drug and any illicit drug other than marijuana have similar prevalence levels across the three racial/ethnic groups. For Hispanic, Black/African American, and White 12th grade students the prevalence levels of past 30-day use of any illicit drug in 2022 were 18%, 22%, and 19%, respectively. For the outcomes of any illicit drug other than marijuana the corresponding prevalence levels were 3%, 3%, and 2%.

" White 12th grade students had the highest 12-month prevalence of salvia, Vicodin, Ritalin, crystal methamphetamine, misuse of over-the-counter cough/cold medicines, rohypnol, GHB, steroids, and androstenedione.

" Hispanic 12th grade students have the highest 12-month prevalence for a few drugs, but they are drugs with low prevalence and the difference is small in terms percentage points. For example, they have the highest level of dissolvable tobacco, by a difference of 0.7 percentage points (prevalence is 1.8% for Hispanics compared to 1.1% for Black/African American and White students). They also have the highest level of synthetic marijuana, by a difference of 0.2 percentage points (prevalence is 2.8% for Hispanic, 2.6% for Black/African American and 1.4% for White students).

" Black/African American 12th grade students had higher levels of alcohol use than Hispanics and Whites in 2022. The percentage of 12th grade students who had a drink of alcohol in the past 12 months was 57% for Black/African American teens, compared to 41% for Hispanics and 32% for Whites. Prevalence levels for getting drunk in the past 12 months for the three racial/ethnic groups were 37%, 21%, and 16%, respectively. Prevalence of 50using a flavored alcoholic beverage in the last 12 months was 42%, 28%, and 17%, respectively. Binge drinking in the last 30 days was also highest among Black/African American 12th graders, at 16%, compared to 8% for Hispanics and 5% for Whites.

" Black/African American 12th grade students had higher levels of nicotine use than their White and Hispanic peers. Prevalence of cigarette smoking in the past 30 days in 12th grade was 5% for Black/African American teens, compared to 1.9% for Hispanic and 1.2% for White teens. In recent years nicotine vaping has become the more common way for teens to use nicotine, and in 2022 the prevalence level among Black/African Americans was 25%, compared to 13% for Hispanic and 11% for White students.

" Black/African American 12th grade students had higher levels of use for any prescription drug, with past 12-month prevalence at 5%, compared to 4% for Hispanics and 3% for Whites. This difference is driven in part by amphetamines, for which past 12-month prevalence among Black/African American 12th graders is 3%, compared to 2% for Hispanic and 1% for Whites."

"In 2022, 22.0 percent of people aged 12 or older (or 61.9 million people) used marijuana in the past year regardless of mode (Figures 13 and 14 and Table A.5B). The percentage was highest among young adults aged 18 to 25 (38.2 percent or 13.3 million people), followed by adults aged 26 or older (20.6 percent or 45.7 million people), then by adolescents aged 12 to 17 (11.5 percent or 2.9 million people).

"Among people aged 12 or older in 2022 who used marijuana in the past year, the most common mode of marijuana use was smoking (78.4 percent or 48.3 million people), followed by eating or drinking (47.1 percent or 29.0 million people); vaping (36.7 percent or 22.7 million people); dabbing waxes, shatter, or concentrates (17.5 percent or 10.8 million people); applying lotion, cream, or patches to the skin (9.3 percent or 5.7 million people); putting drops, strips, lozenges, or sprays in the mouth or under the tongue (6.9 percent or 4.2 million people); taking pills (2.7 percent or 1.6 million people); and some other way (0.1 percent or 54,000 people) (Figure 16 and Table A.6B).20

"Smoking was the most common mode of marijuana use across age groups. Among people in 2022 who used marijuana in the past year, 85.9 percent of young adults aged 18 to 25, 76.6 percent of adolescents aged 12 to 17, and 76.3 percent of adults aged 26 or older smoked marijuana.

"Other common modes of marijuana use in 2022 among past year marijuana users varied by age group. Among adolescents aged 12 to 17 who used marijuana in the past year, more than half (59.7 percent) vaped marijuana, followed by about one third (36.1 percent) who ate or drank marijuana, then by almost one quarter who dabbed waxes, shatter, or concentrates (23.3 percent). Among young adults aged 18 to 25 who used marijuana in the past year, about half ate or drank marijuana (50.2 percent) or vaped it (50.0 percent), followed by those who dabbed waxes, shatter, or concentrates (29.5 percent). Among adults aged 26 or older who were past year marijuana users, 46.9 percent ate or drank it, followed by 31.3 percent who vaped it, then by 13.7 percent who dabbed waxes, shatter, or concentrates. Other modes of marijuana use were less common across all three age groups."

"The illicit drugs with the largest number of recent initiates in 2016 were marijuana (2.6 million new users), prescription pain relievers (2.1 million new misusers), prescription tranquilizers (1.4 million new misusers), prescription stimulants (1.4 million new misusers), hallucinogens (1.2 million new users), and cocaine (1.1 million new users). In addition, there were 4.6 million new users of alcohol, 1.8 million people who tried a cigarette for the first time in the past year, and 1.2 million people who first used smokeless tobacco in the past year.³⁴

"Figure 12 provides an overview of the average age at first use (or first misuse for prescription drugs) in 2016 among recent initiates aged 12 to 49. For many substances, the average age at initiation in 2016 was younger than age 20, with average ages of 17.4 years for alcohol, 18.0 years for cigarettes, 18.2 years for inhalants, 19.3 years for marijuana, and 19.6 years for any hallucinogen. However, some substances had older average initiation ages, such as methamphetamine (24.6 years) and heroin (25.5 years). The average ages at initiation for prescription drug misuse were in the early to mid-20s (23.9 years for prescription tranquilizers, 24.3 years for prescription stimulants, 24.4 years for prescription pain relievers, and 24.8 years for prescription sedatives)."

"Cocaine use includes the use of crack. Estimates of crack use are presented separately as well. Among people aged 12 or older in 2022, 1.9 percent (or 5.3 million people) used cocaine in the past year (Figures 13 and 18 and Table A.5B). The percentage was highest among young adults aged 18 to 25 (3.7 percent or 1.3 million people), followed by adults aged 26 or older (1.8 percent or 3.9 million people), then by adolescents aged 12 to 17 (0.2 percent or 40,000 people).

"In 2022, an estimated 0.3 percent of people aged 12 or older (or 918,000 people) used crack in the past year (Table A.5B). The percentage of crack use could not be calculated with sufficient precision for adolescents aged 12 to 17.13 The percentage among adults aged 26 or older (0.4 percent or 877,000 people) was higher than the percentage among young adults aged 18 to 25 (0.1 percent or 39,000 people).

"By Race/Ethnicity

"In 2022, cocaine use in the past year among people aged 12 or older did not differ significantly among racial or ethnic groups (Table B.7B). Percentages ranged from 0.9 percent among Asian people to 2.3 percent among American Indian or Alaska Native people. However, Black people (0.9 percent) were more likely to have used crack in the past year compared with White (0.3 percent) or Hispanic people (0.1 percent)."

"Among the 41.1 million current cigarette smokers aged 12 or older in 2022 (see the section on Cigarette Use), 24.1 million people (or 58.7 percent) were daily cigarette smokers (Figure 6). The percentage of people who were daily cigarette smokers among current cigarette smokers was highest among adults aged 26 or older (62.4 percent or 23.1 million people), followed by young adults aged 18 to 25 (26.7 percent or 996,000 people), then by adolescents aged 12 to 17 (3.1 percent or 10,000 people) (Table A.1B).

"Among the 24.1 million daily cigarette smokers aged 12 or older in 2022, 9.6 million people (or 39.8 percent) smoked one or more packs of cigarettes per day (Figure 6 and Table A.1B). Among daily cigarette smokers, adults aged 26 or older were more likely than young adults aged 18 to 25 to smoke one or more packs of cigarettes per day (40.8 vs. 17.5 percent). Estimates for smoking one or more packs of cigarettes per day could not be calculated with sufficient precision for adolescent daily smokers aged 12 to 17.^13"

"In 2022 past-year use of crack cocaine was at or near historic lows. Annual use levels among 8th, 10th, and 12th grade students were all less than 1%. Like cocaine, crack use dropped sharply from 1986—when its use was first measured—through 1991. Consistent with other illicit drugs, its prevalence then increased during the 1990s drug relapse, peaked in the late 1990s, and has since declined to today’s low levels of use.

"Questions on crack cocaine were first introduced into the survey in 1986, when information gathered routinely in MTF showed some indirect evidence of the rapid spread of crack cocaine. For example, we found that the proportion of all 12th graders reporting that they had ever smoked cocaine (as well as used it in the past year) more than doubled between 1983 and 1986, from 2.4% to 5.7%. In the same period, the proportion of those who said that they had both used cocaine during the prior year and at some time had been unable to stop using it when they tried doubled (from 0.4% to 0.8%). In addition, between 1984 and 1986, the proportion of 12th graders reporting daily use of cocaine also doubled (from 0.2% to 0.4%). We think it likely that the rapid advent of crack use during this period was reflected in all of these changes, though we did not yet have a direct measure of its use.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns."

"In 2018, an estimated 164.8 million people aged 12 or older used a substance (i.e., tobacco, alcohol, or an illicit drug) in the past month (Figure 1). This number of current substance users corresponds to 60.2 percent of the population. About 2 out of 5 people aged 12 or older (108.9 million, or 39.8 percent) did not use substances in the past month.

"The 164.8 million current substance users in 2018 include 139.8 million people who drank alcohol, 58.8 million people who used a tobacco product, and 31.9 million people who used an illicit drug (2018 DT 7.3). These numbers are not mutually exclusive because respondents could have used more than one type of substance (e.g., tobacco products and alcohol) in the past month.

"Although about half of the people aged 12 or older (51.1 percent) drank alcohol in the past month and 1 in 5 (21.5 percent) used a tobacco product, use of illicit drugs was less common (Table A.1B). About 1 in 9 people aged 12 or older (11.7 percent) used an illicit drug in the past month."

"In 2022 past-year use of crack cocaine was at or near historic lows. Annual use levels among 8th, 10th, and 12th grade students were all less than 1%. Like cocaine, crack use dropped sharply from 1986—when its use was first measured—through 1991. Consistent with other illicit drugs, its prevalence then increased during the 1990s drug relapse, peaked in the late 1990s, and has since declined to today’s low levels of use."

"Among the 137.4 million current alcohol users aged 12 or older in 2022, 61.2 million people (or 44.5 percent) were past month binge drinkers (Figure 8). Among past month binge drinkers, 16.1 million people were past month heavy drinkers. The 16.1 million heavy drinkers represent 26.3 percent of current binge drinkers and 11.7 percent of current alcohol users.²⁰

"Any Alcohol Use

"Among people aged 12 or older in 2022, 48.7 percent (or 137.4 million people) drank alcohol in the past month (Figure 9 and Table A.1B). The percentage was highest among adults aged 26 or older (53.4 percent or 118.2 million people), followed by young adults aged 18 to 25 (50.2 percent or 17.5 million people). The percentage was lowest among adolescents aged 12 to 17 (6.8 percent or 1.8 million people).

"By Race/Ethnicity

"Among people aged 12 or older in 2022, 53.4 percent of White people drank alcohol in the past month (Table B.4B). This percentage was higher than the percentages of people in other racial or ethnic groups. Hispanic people had a higher estimate of past month alcohol use (43.6 percent) compared with Asian people (36.7 percent). The estimate of current alcohol use could not be calculated with sufficient precision for Native Hawaiian or Other Pacific Islander people.¹³"

According to the National Survey on Drug Use and Health, in the United States in 2023 among people aged 12 and older there were an estimated 22,276,000 lifetime users of MDMA, 2,153,000 past-year users, and 471,000 past-month users.

"Trends in Substance Use
"Past month alcohol use, binge alcohol use, and illicit drug use remained relatively stable among black adults between 2002 and 2008 (Figure1).^4,5

"Past Month Alcohol and Illicit Drug Use
"Combined 2004 to 2008 data indicate that, in the past month, 44.3 percent of black adults used alcohol, 21.7 percent reported binge alcohol use, and 9.5 percent used an illicit drug (Figure 2).

"Rates of past month alcohol use and binge alcohol use were lower among black adults than the national averages. The rate of past month illicit drug use among black adults, however, was higher than the national average.

"Substance Use among Young Adults (Aged 18 to 25)
"Rates of past month and binge alcohol use were considerably lower among young black adults than the national average of young adults (48.6 vs. 61.1 percent and 25.3 vs. 41.6 percent, respectively) (Figure 3).

"Past month illicit drug use among young black adults was slightly lower than the national average (18.7 vs. 19.7 percent).

"Substance Use among Older Adults (Aged 65 or Older)
"Older black adults had a rate of past month alcohol use that was considerably lower than the national average of older adults (20.3 vs. 38.3 percent) (Figure 4). Their rates of binge alcohol use and past month illicit drug use, however, did not differ significantly from the national averages.

"Substance Use among Women
"Compared with the national averages, adult black females had lower rates of past month alcohol use and binge alcohol use and a slightly higher rate of past month illicit drug use (Table 1). Patterns varied by age group.

"Among women aged 18 to 44 who were pregnant at the time of the survey interview, blacks had a higher rate of binge alcohol use than the national average (8.1 vs. 3.6 percent) (Figure 5). As for past month alcohol use and past month illicit drug use, the rates appear to have been higher than the national average of pregnant women, but the differences were not statistically significant.

"Substance Use among Men
"Compared with the national averages, adult black males had lower rates of past month alcohol use and binge alcohol use and a slightly higher rate of past month illicit drug use (Table 2). Patterns varied by age group."

"• Use of illicit drugs and alcohol was more common among current cigarette smokers than among nonsmokers in 2012, as in previous years since 2002. Among persons aged 12 or older, 23.0 percent of past month cigarette smokers reported current use of an illicit drug compared with 5.2 percent of persons who were not current cigarette smokers. Among youths aged 12 to 17 who smoked cigarettes in the past month, 54.6 percent also used an illicit drug compared with 6.4 percent of youths who did not smoke cigarettes.

"• Past month alcohol use was reported by 65.4 percent of current cigarette smokers compared with 48.3 percent of those who did not use cigarettes in the past month. This association also was found for binge alcohol use (43.6 percent of current cigarette smokers vs. 17.1 percent of current nonsmokers) and heavy alcohol use (15.8 vs. 3.9 percent, respectively)."

"• In 2013, among persons aged 12 or older, the rate of current illicit drug use was 3.1 percent among Asians, 8.8 percent among Hispanics, 9.5 percent among whites, 10.5 percent among blacks, 12.3 percent among American Indians or Alaska Natives, 14.0 percent among Native Hawaiians or Other Pacific Islanders, and 17.4 percent among persons reporting two or more races.
"• There were no statistically significant differences in the rates of current illicit drug use between 2012 and 2013 for any of the racial/ethnic groups. Between 2002 and 2013, the rate of current illicit drug use increased from 8.5 to 9.5 percent for whites. Among blacks, the rate increased from 8.7 percent in 2003 and 2004 to 10.5 percent in 2013 (Figure 2.12)."

"• The annual average rate of past month cigarette use in 2012 and 2013 among women aged 15 to 44 who were pregnant was 15.4 percent (Figure 4.5). The rate of current cigarette use among women aged 15 to 44 who were pregnant was lower than that among women who were not pregnant (24.0 percent). This pattern was also evident among women aged 18 to 25 (21.0 vs. 26.2 percent for pregnant and nonpregnant women, respectively) and among women aged 26 to 44 (11.8 vs. 25.4 percent, respectively). Rates of current cigarette use in 2012-2013 among pregnant women aged 15 to 44 were 19.9 percent in the first trimester, 13.4 percent in the second trimester, and 12.8 percent in the third trimester.
"• The annual average rates of current cigarette use among women aged 15 to 44 who were not pregnant decreased from 30.7 percent in 2002-2003 to 24.0 percent in 2012-2013 (Figure 4.5). However, the prevalence of cigarette use among pregnant women in this age range did not change significantly during the same time period (18.0 percent in 2002-2003 and 15.4 percent in 2012-2013)."

"UNODC, UNAIDS, WHO and the World Bank jointly estimate that some 11.2 million persons worldwide injected drugs in 2020. There has been no measurable change in the estimated global prevalence of injecting drug use from the previous estimate for 2019, which was also 0.22 per cent of the population aged 15–64. However, any trend data must be viewed with caution as the methodologies used to produce national or subnational PWID population size estimations may have changed.

"Approximately 59 per cent of PWID worldwide reside in East and South-East Asia, Eastern Europe and North America. Injecting drug use remains particularly prevalent in Eastern Europe and, to a lesser extent, Central Asia and Transcaucasia, and North America, with rates that are 5.8, 2.6 and 2.5 times the global average, respectively."

"PWID [People Who Inject Drugs] accounted for 9 per cent of new adult HIV infections worldwide in 2020, with the proportion rising to 20 per cent outside sub-Saharan Africa, where HIV disproportionately affects adolescent girls and young women.⁹¹ UNODC, UNAIDS, WHO and the World Bank jointly estimated that in 2020 approximately one in every eight (12.4 per cent, down from 12.6 per cent in 2019) PWID worldwide were living with HIV, amounting to 1.4 million people.

"The latest UNAIDS estimates suggest that in 2020, PWID had a risk of acquiring HIV that was 35 times greater than that of people who do not inject drugs.⁹² This underlines the greater vulnerability of PWID to HIV infection than have other key population groups more likely to be exposed to HIV or to transmit it.^{93, 94}

"As a tool to monitor progress in the testing and treatment of HIV, UNAIDS established the 90-90-90 targets in 2014 with the aim that by 2020, 90 per cent of people living with HIV would know their HIV status, 90 per cent of those diagnosed would be receiving antiretroviral treatment, and 90 per cent of those receiving treatment would have achieved viral suppression.⁹⁵ The sub-population of PWID living with HIV seems to be particularly far from these targets as shown by a study in selected countries in Europe and Central Asia.⁹⁶

"Eastern Europe and South-West Asia continue to be the subregions with the highest estimated prevalence of HIV among PWID, with more than one in four PWID in those two regions living with HIV. According to UNAIDS, Eastern Europe and Central Asia (as defined geographically by UNAIDS) is the region with the world’s fastest growing HIV epidemic, with the annual number of new adult HIV infections increasing by an estimated 43 per cent between 2010 and 2020. This is in contrast to a 31 per cent decline in the annual number of new adult HIV infections globally in the same period.⁹⁷"

"• In 2013, as in prior years, the rate of current illicit drug use among persons aged 12 or older was higher for males (11.5 percent) than for females (7.3 percent). Males were more likely than females to be current users of several different illicit drugs, including marijuana (9.7 vs. 5.6 percent), cocaine (0.8 vs. 0.4 percent), and hallucinogens (0.7 vs. 0.3 percent).
"• In 2013, the rate of current illicit drug use was higher for males than females aged 12 to 17 (9.6 vs. 8.0 percent). This represents a change from 2012, when the rates of current illicit drug use were similar among males and females aged 12 to 17 (9.6 and 9.5 percent, respectively), and reflects a decrease in the rate of current illicit drug use among females from 2012 to 2013. Likewise, in 2013, the rate of current marijuana use was higher for males than females aged 12 to 17 (7.9 vs. 6.2 percent), which is a change from 2012 when the rates of current marijuana use for males and females were similar (7.5 and 7.0 percent).
"• The rate of current marijuana use among males aged 12 to 17 declined from 9.1 percent in 2002 to 6.9 percent in 2006, then increased between 2006 and 2011 (9.0 percent) (Figure 2.11). The rate decreased from 2011 to 2012 (7.5 percent) and remained stable in 2013 (7.9 percent). Among females aged 12 to 17, the rate of current marijuana use decreased from 7.2 percent in 2002 and 2003 to 6.2 percent in 2013."

"In 2022, the prevalence of current tobacco use among males aged 15 years and over was 34.4%. Of these, 83% consumed smoked tobacco products (global prevalence of 28.4%); see Fig. 6. These male smokers mostly used cigarettes (90%) with a prevalence level of 25.5%. In the same year, 7.4% of females of the same age were current users of any form of tobacco. Compared with males, a somewhat lower proportion used any smoking tobacco (69% at a prevalence of 5.1%.). However, of those who smoked, 86% smoked cigarettes (prevalence of 4.4%); see Fig. 7.

"In terms of numbers of adult users, in 2022, there were an estimated 1.245 billion current tobacco users in the world, among whom 995 million were current tobacco smokers. Among smokers, around 890 million were currently smoking cigarettes; see Fig. 7. Of the estimated 1.245 billion current tobacco users globally, around 1.022 billion were men and 224 million were women. These numbers do not include adolescents aged under 15.

"In the European Region, 25.3% of all people aged 15 years and over were current users of tobacco; with almost all (98% among males and 99% among females) using a smoking product and again almost all using cigarettes; see Table 7.

"The lowest proportion of smokers among tobacco users is seen in the South-East Asia Region where 26.5% of people were current users of tobacco with less than half of these using a smoked tobacco product. There was a marked difference by sex with 55% of males using a smoked product compared with 14% of female tobacco users who were smokers (see Table 7).

"The largest proportion of smokers among tobacco users is found in the high-income country group, where 22.2% of adults were current tobacco users (27.2% of males and 17.2% of females). Of these, the large majority were current smokers (25.2% of males and 16.5% of females). This translates to 94% of current tobacco users being smokers (93% of male tobacco users and 96% of female tobacco users).

"The smallest proportion of smokers among tobacco users is found in the lower middle-income country group, where on average 22.7% of adults were current tobacco users in 2022, with only 12.9% using a smoked product.

"Among tobacco smokers globally, just under 90% smoked cigarettes. The proportion was highest in the Western Pacific Region, where almost all smokers smoke cigarettes, and lowest in the South-East Asia Region, where almost 80% of smokers used cigarettes."

"It is estimated that 61.3 million people (range: 36.5 million–78.1 million) had used opioids in the past year worldwide in 2020. This includes people who use opiates and people who use pharmaceutical opioids for non-medical purposes and corresponds to 1.2 per cent of the global population aged 15–64. The majority of people who use opioids are men – an estimated 85% based on data from 26 countries.

"Since 2017, both quantitative and qualitative information have pointed to a moderate increase in opioid use, with possible stabilization in 2020. Qualitative reporting suggests that between 2010 and 2017 most countries observed decreases in opioid use. However, it is challenging to confirm long-term trends in opioid use by means of quantitative estimates, since it is not always possible to determine if changes were the result of actual phenomena or merely the result of improved data. For example, global estimates show a sharp increase in use between 2016 and 2017, but this mainly represents new estimates made available for Asia and Africa.

"About half of the users of opioids had used opiates, mainly heroin and opium, in the past year. Opiate use includes, most often, the use of heroin and opium, but also non medical use of codeine and morphine. Opiate use constitutes part of overall opioid use and follows similar trends."

"Primarily on the basis of self-reported responses to general population surveys, a total of 34 million people aged 15–64, or 0.7 per cent of the global population, are estimated to have used amphetamines in the past year, and almost 20 million (0.4 per cent) are estimated to have used “ecstasy”-type substances. Some of those users had used both types of substances. The two most commonly used amphetamines are amphetamine and methamphetamine.

"The global estimate of amphetamines use was similar in 2010, with 33 million past year users or 0.7% of the population aged 15-64. However, these estimates have to be interpreted with caution owing to the lack of data from major consumer countries in Asia where other market indicators, such as seizures and prices, suggest an expansion over the last decade.

"Qualitative information based on perceptions of trends reported by national experts to UNODC shows a continued increase both in terms of the use of amphetamines and the number of people in treatment for amphetamines over the past decade.²⁵ However, data for 2020 show that this increasing trend has paused and that the number of people in treatment for amphetamines may have decreased, consistent with an overall decrease in treatment as a result of the COVID-19 pandemic.^e Trends derived from such qualitative information are consistent with the available supply indicators, such as prices and seizures, which indicate continued global expansion of the market for amphetamines. Qualitative information of this type suffers from methodological limitations, but it has an advantage in that it takes into consideration small-scale studies and expert observations regarding countries where drug use surveys are not regularly implemented.

"Qualitative information on trends in the use of “ecstasy” was not reported by countries before the implementation by UNODC of its new data collection tool (the updated annual report questionnaire, which came into use in 2020), thus qualitative reports of trends in “ecstasy” use are limited to the period 2019– 2020. These reports suggest a moderate increase globally. At the same time, studies from countries where “ecstasy” is used in recreational settings suggest that the use of “ecstasy” declined more than any other drug during the pandemic in those countries.^f"

"Approximately 59 per cent of PWID worldwide reside in East and South-East Asia, Eastern Europe and North America. Injecting drug use remains particularly prevalent in Eastern Europe and, to a lesser extent, Central Asia and Transcaucasia, and North America, with rates that are 5.8, 2.6 and 2.5 times the global average, respectively."

"• An estimated 6.4 percent, or 7.3 million, of full-time workers reported use of marijuana during the past month (Tables 2.2 and 2.3).
"• Adults aged 26 to 34 were only about half as likely as 18- to 25-year-olds to be past month marijuana users (8.0 vs. 15.9 percent). Past month use of marijuana was lower with increasing age (Table 2.2).
"• The prevalence of past month marijuana use was higher for males than females (7.9 vs. 4.3 percent, respectively) (Table 2.2).
"• An estimated 11.0 percent of workers reporting two or more races used marijuana during the past month. This was higher than among non-Hispanic white adults (6.9 percent). Fewer Hispanic adults (4.6 percent) reported past month marijuana use than non-Hispanic white adults who reported two or more races (Table 2.2).
"• Higher educational attainment and higher family income were associated with a lower prevalence of current marijuana use (Table 2.3)."

"Worldwide, there were an estimated 192 million past-year users of cannabis in 2018, corresponding to 3.9 per cent of the global population aged 15–64. The past-year use of cannabis is substantially higher than the global average in North America (14.6 per cent), Australia and New Zealand (10.6 per cent) and West and Central Africa (9.3 per cent).

"In 2009, cannabis use was reported to be stabilizing or declining in countries with established cannabis markets, such as in Western and Central Europe, North America and Australia and New Zealand, but that trend was offset by increasing use in many countries in Africa and Asia.²¹ A decade later, cannabis use in Western and Central Europe has remained stable overall and has increased considerably in North America, Africa and Asia.²²"

"• In 2013, 5.7 million persons aged 12 or older used marijuana on a daily or almost daily basis in the past 12 months (i.e., on 300 or more days in that period), which was an increase from the 3.1 million daily or almost daily users in 2006 (Figure 2.15). The number of daily or almost daily users of marijuana in 2013 represented 17.4 percent of past year users.
"• In 2013, 8.1 million persons aged 12 or older used marijuana on 20 or more days in the past month, which was an increase from the 5.1 million daily or almost daily past month users in 2005 to 2007 (Figure 2.15). The number of daily or almost daily users in 2013 represented 41.1 percent of past month marijuana users."

"• In 2013, there were 601,000 persons aged 12 or older who had used cocaine for the first time within the past 12 months; this averages to approximately 1,600 initiates per day. This estimate was similar to the number in 2008 to 2012 (ranging from 623,000 to 724,000). The annual number of cocaine initiates in 2013 was lower than the estimates from 2002 through 2007 (ranging from 0.9 million to 1.0 million).
"• The number of initiates of crack cocaine ranged from 209,000 to 353,000 in 2002 to 2008 and declined to 95,000 in 2009. The number of initiates of crack cocaine has been similar each year since 2009 (e.g., 58,000 in 2013).
"• In 2013, most (81.9 percent) of the 0.6 million recent cocaine initiates were aged 18 or older when they first used. The average age at first use among recent initiates aged 12 to 49 was 20.4 years. The average age estimates have remained fairly stable since 2002."

"Data on people in drug treatment who mentioned cocaine products as their primary drug are limited to 26 countries, 20 of them in Europe, and show an increasing trend over the past decade. However, 70 per cent of the countries reported a decrease in the number of such patients in 2020, compared with the previous year, possibly confirming the general decrease in treatment delivery during the pandemic rather than a decrease in the number of people with cocaine use disorders.

"Wastewater-based epidemiology offers an additional source of information on trends in consumption of cocaine,^d although this method is limited to a relatively small number of cities, concentrated in Europe, followed by Oceania and Asia.⁴⁰ Long-term trend data with relatively good subregional coverage is only available for Western and Central Europe, although there were available paired data points for 2019 and 2020 for 66 cities across various regions. On average, the standardized quantity of findings of benzoylecgonine, the metabolite that signals the passing of cocaine through the human body, in wastewater dropped by 13 per cent from 2019 to 2020. However, the number of cities witnessing increased benzoylecgonine levels was almost identical to the number of cities experiencing decreases. As data became available for 2021, the trend seems to have returned to its pre-pandemic increasing trajectory. Overall, a 17 per cent increase in average loads was observed in 66 locations with available paired measurements. While 19 locations have recorded a decline and 9 locations a stable situation,^e 38 locations witnessed increases between 2020 and 2021.^f"

"Fifty-two percent of Hispanic youth report using illicit drugs in the past year (vs. 42 percent for African-American youth and 40 percent for Caucasian teens). They are also more likely than other teens to have used prescription medicine, Ecstasy or cocaine/crack to get high.

"Marijuana use levels are of significant concern among Hispanic youth. Half of Hispanic teens report smoking marijuana in the past year (43 percent more than Caucasian teens and 25 percent more than African-American youth)."

Amphetamine-Type Stimulants

"In 2014, the estimated 1.6 million people aged 12 or older who were current nonmedical users of stimulants included 569,000 people who were current methamphetamine users (Figure 8). Thus, almost two thirds of current nonmedical users of stimulants in 2014 who were aged 12 or older reported current nonmedical use of prescription stimulants but not methamphetamine.
"These numbers of nonmedical users of stimulants and methamphetamine users represent 0.6 percent of the population aged 12 or older who were current nonmedical users of stimulants (Figure 9) and 0.2 percent who were current users of methamphetamine in 2014 (Figure 10). The percentage of the population aged 12 or older in 2014 who were current nonmedical users of stimulants was higher than the percentages for most years between 2005 and 2012. Meanwhile, the percentage of the population aged 12 or older in 2014 who were current users of methamphetamine was similar to the percentages for most years between 2002 and 2013."

"• The prevalence of past month illicit drug use among adult full-time workers was 8.2 percent (Figure 2.3 and Tables 2.2 and 2.3).
"• Nearly one out of five (19.0 percent) workers aged 18 to 25 used illicit drugs during the past month. This was a higher percentage than among the 26-to-34 (10.3 percent), 35-to-49 (7.0 percent), and 50-to-64 (2.6 percent) age groups (Figure 2.3 and Table 2.2).
"• Males were more likely than females to report past month illicit drug use (9.7 vs. 6.2 percent). Males accounted for about two thirds (6.4 million) of the workers who reported past month illicit drug use (Figure 2.4 and Table 2.2).
"• The prevalence of past month illicit drug use for white adults was 8.8 percent, higher than the prevalence for Asian (2.2 percent) or Hispanic (6.7 percent) adults, and lower than that reported for adults who reported two or more races (13.5 percent). The prevalence of past month illicit drug use by Asians was lower than that reported by all other racial/ethnic groups reported here (Figure 2.5 and Table 2.2)."

"About 1.0 percent of people aged 12 or older (2.7 million) had a prescription drug use disorder in the past year, including 2.0 million people with a pain reliever use disorder, 688,000 with a tranquilizer use disorder, 426,000 with a stimulant use disorder, and 154,000 with a sedative use disorder. In 2015, as part of their most recent substance use treatment, 822,000 people received treatment for the misuse of pain relievers, 293,000 people received treatment for tranquilizer misuse, 139,000 received treatment for stimulant misuse, and 116,000 received treatment for sedative misuse.
"Among people aged 12 or older who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse was to relieve physical pain (62.6 percent). Among past year misusers of tranquilizers, the most commonly reported reasons were to relax or relieve tension (44.9 percent) or to help with sleep (20.4 percent). Commonly reported reasons for misuse among stimulant misusers were to help be alert or stay awake, help concentrate, or help study (26.8, 26.5, and 22.5 percent, respectively). Among past year sedative misusers, the most common reason was to help with sleep (71.7 percent). Even if people misused prescription drugs for conditions for which these drugs are typically prescribed (e.g., for pain relief or to help with sleep), use without one’s own prescription or use more often or at a higher dosage than prescribed nevertheless constitutes misuse.
"Among people aged 12 or older who misused pain relievers in the past year, the most common source for the last pain reliever that was misused was from a friend or relative (53.7 percent), and about one third misused a prescription from one doctor. About 1 in 20 people who misused pain relievers bought the last pain reliever they misused from a drug dealer or stranger."

"• The number and percentage of persons aged 12 or older who were current nonmedical users of stimulants in 2013 (1.4 million or 0.5 percent) were similar to those in 2012 (1.2 million or 0.5 percent), but were higher than the estimates in 2011 (970,000 or 0.4 percent)."

"• Between 1982 and 1992, among 12th graders levels of amphetamine use in the past 12 months (other than use that was ordered by a physician) fell by nearly two thirds, from 20.3% to 7.1%. Levels among college students fell even more over the same interval, from 21.1% to 3.6%. During the relapse phase in the drug epidemic in the 1990s, annual amphetamine use increased by about half among 8th and 10th graders between 1991 and 1996, and also increased among 12th graders and college students between 1992 and 1996. After 1996 the age groups diverged, with amphetamine use declining gradually and substantially among 8th graders—where use is now a fraction of what it was in 1996 — but continuing to rise among 12th graders (and eventually 10th graders), college students, and young adults until about 2002. The declines continued in the upper grades through about 2008 but through 2013 for 8th graders. Since 2009, annual prevalence has increased among 12th graders (from 6.6% to 8.1% in 2014), perhaps as a result of more students using amphetamines to help their academic work. Among students in college, amphetamine use rose even more sharply from 5.7% in 2008 to 10.1% in 2014, likely for the same reason. Young adults, who include the college students, showed less of an increase over the same interval, from 5.3% in 2008 to 8.0% in 2014. The pattern of cross-age-group change suggests a cohort effect at work for amphetamine use. Since the late 1990s there has been a greater difference between use among 8th graders and use by older students, suggesting that an age effect has emerged, possibly due to the older students becoming more likely to use amphetamines to aid their academic performance. (“To help me study” was the highest endorsed reason 12th graders gave for amphetamine use in 2012 and the third highest in 2014.)

"Among 12th graders, the increase in nonmedical use of amphetamines (and a concurrent decrease in disapproval) began in 1993; this followed a sharp drop in perceived risk a year earlier (which, as we have noted for a number of drugs, often serves as a leading indicator). Following a period of decline, perceived risk among 12th graders increased gradually from 1995 through 2009.¹

"• Use of the stimulant drug Ritalin outside of medical supervision showed a distinct increase around 1997 — with annual prevalence among 12th graders going from 0.1% in 1992 to 2.8% in 1997 — and then stayed level for a few years (see Appendix E, Table E-22). Because of its increasing importance, a differently structured question was introduced for Ritalin use in 2001 (2002 in the follow-ups of college students and young adults). This new question, which we prefer to the original, does not use a prior branching question and produced somewhat higher prevalence levels. Results from the new question suggest an ongoing decline in Ritalin use, with prevalence levels in 2014 less than half of what they were when first measured in 2001-02.

"• Another stimulant used in the treatment of the symptoms of attention deficit hyperactivity disorder (ADHD) is the amphetamine drug Adderall. A new question on its non-medical use was introduced in 2009; annual prevalence levels in 2009 through 2014 were higher than those for Ritalin in all five populations. This suggests that Adderall may have to some degree replaced the use of Ritalin and may help to account for the declines that we have been observing for the latter drug. Annual prevalence of Adderall changed rather little between 2009 and 2014 in 8th and 10th grades, although the levels seem to be drifting down. In 12th grade, however, annual prevalence has risen from 5.4% in 2009 to 7.6% in 2012, followed by non-significant declines over the next two years. The absolute prevalence levels in 2014 are fairly high, particularly among 12th graders (6.8%), young adults (7.8%), and college students (9.6%)."

"• Approximately 3 million full-time workers (2.6 percent) aged 18 to 64 met the criteria for past year illicit drug dependence or abuse (Figure 2.3 and Table 2.4).

"• Approximately 7.5 percent of 18- to 25-year-old workers had past year illicit drug dependence or abuse. This was higher than among all other age groups studied (26- to 34-year-olds [3.3 percent], 35- to 49-year-olds [1.9 percent], and 50- to 64-year-olds [0.7 percent]) (Figure 2.3 and Table 2.4).

"• Males were nearly twice as likely as females to meet the criteria for past year illicit drug dependence or abuse (3.3 vs. 1.8 percent) (Figure 2.4 and Table 2.4).

"• Hispanics (3.2 percent) had a higher prevalence of past year illicit drug dependence or abuse than non-Hispanics (2.6 percent) (Figure 2.8 and Table 2.4).

"• Within non-Hispanic subgroups, Asians had the lowest prevalence of past year illicit drug dependence or abuse (1.1 percent). This was lower than non-Hispanic white adults (2.5 percent), black (2.9 percent) adults, American Indian or Alaska Native (4.5 percent) adults, and adults reporting two or more races (4.3 percent) (Figure 2.8 and Table 2.4)."

"• Nonmedical use of psychotherapeutics includes nonmedical use of any prescription-type pain relievers, tranquilizers, stimulants, or sedatives. Over-the-counter substances are not included. In 2013, there were approximately 2.0 million persons aged 12 or older who used psychotherapeutics nonmedically for the first time within the past year, which averages to about 5,500 initiates per day. The number of new nonmedical users of psychotherapeutics in 2013 was lower than the estimates for prior years from 2002 through 2012 (ranging from 2.3 million to 2.8 million).
"• In 2013, the numbers of initiates were 1.5 million for pain relievers, 1.2 million for tranquilizers, 603,000 for stimulants, and 128,000 for sedatives (Figure 5.6).
"• The number of new nonmedical users of pain relievers in 2013 (1.5 million) was lower than the numbers in 2002 through 2012 (ranging from 1.9 million to 2.5 million) (Figure 5.6). The number of past year initiates for nonmedical use of tranquilizers has been fairly stable from 2002 to 2013 (ranging from 1.1 million to 1.4 million). The number of initiates for nonmedical use of stimulants in 2013 was similar to the numbers in 2003, 2005, and in 2007 to 2012 (ranging from 602,000 to 715,000), but was lower than the numbers in 2002, 2004, and 2006 (ranging from 783,000 to 846,000). The number of initiates for nonmedical use of sedatives in 2013 was similar to the numbers in 2002, 2003, 2007 to 2009, 2011, and 2012 (ranging from 159,000 to 209,000), but was lower than the numbers in 2004 to 2006 and in 2010 (ranging from 240,000 to 267,000).
"• In 2013, the average age at first nonmedical use of any psychotherapeutics among recent initiates aged 12 to 49 was 22.4 years. Average ages at first nonmedical use were 21.6 years for stimulants, 21.7 years for pain relievers, 25.0 years for sedatives, and 25.4 years for tranquilizers. All of these 2013 estimates were similar to the corresponding estimates in 2012.
"• In 2013, the number of new nonmedical users of OxyContin® aged 12 or older was 436,000, which was similar to the estimates for prior years from 2004 through 2012. The average age at first use of OxyContin® among past year initiates aged 12 to 49 was similar in 2012 and 2013 (22.0 and 23.6 years, respectively)."

"Antidepressants were the third most common prescription drug taken by Americans of all ages in 2005–2008 and the most frequently used by persons aged 18–44 years. From 1988–1994 through 2005–2008, the rate of antidepressant use in the United States among all ages increased nearly 400%."

"• Among young adults aged 18 to 25, the rate of current nonmedical use of psychotherapeutic drugs in 2013 (4.8 percent) was similar to the rates in 2011 (5.0 percent) and 2012 (5.3 percent), but it was lower than the rates in 2002 to 2010 (ranging from 5.5 to 6.5 percent) (Figure 2.9). The rate of current nonmedical use of pain relievers among young adults in 2013 (3.3 percent) was lower than the rates in 2012 (3.8 percent) and in 2002 to 2010 (ranging from 4.1 to 5.0 percent), but it was similar to the rate in 2011 (3.6 percent)."

"In 2004, 6.0 million persons were current users of psychotherapeutic drugs taken nonmedically (2.5 percent). These include 4.4 million who used pain relievers, 1.6 million who used tranquilizers, 1.2 million who used stimulants, and 0.3 million who used sedatives. These estimates are all similar to the corresponding estimates for 2003.
"There were significant increases in the lifetime prevalence of use from 2003 to 2004 in several categories of pain relievers among those aged 18 to 25. Specific pain relievers with statistically significant increases in lifetime use were Vicodin®, Lortab®, or Lorcet® (from 15.0 to 16.5 percent); Percocet®, Percodan®, or Tylox® (from 7.8 to 8.7 percent); hydrocodone products (from 16.3 to 17.4 percent); OxyContin® (from 3.6 to 4.3 percent); and oxycodone products (from 8.9 to 10.1 percent)."

"In the United States, there are indications of an increase in NPS use among certain user groups between 2009 and 2013; the prevalence of lifetime use of a 'novel psychoactive substance' among the population aged 12-34 was 1.2 per cent in 2013.²³⁵ There are signs of declining use of synthetic cannabinoids among secondary school students in the United States. The prevalence of past-year use of synthetic cannabinoids among twelfth-grade students decreased from 11.4 per cent in 2011 to 5.2 per cent in 2015.²³⁶ This is associated with an increase, over the same period, in the perceived risk of taking synthetic cannabinoids among the same group. The use of NPS with stimulant effects (reported as “bath salts“) among twelfth graders remained stable at 1 per cent in 2015. The prevalence of the use of synthetic cannabinoids among eighth, tenth and twelfth graders has declined to the lowest levels since the collection of such data began. However, the large amount of synthetic cannabinoids seized between 2012 and 2014 (more than 93 tons) and the large number of calls to poison centres for problems related to the use of synthetic cannabinoids (3,682 in 2014 and 7,779 in 2015)²³⁷ indicate the continued presence and use of this NPS group in the United States."

"With between 9.4 million and 28.2 million estimated past-year users in 2012, its use declined globally in the period 2010-2012, mainly in Western and Central Europe. Nevertheless, Oceania (2.9 per cent), North America (0.9 per cent) and Europe (0.5 per cent) remain regions with prevalence rates higher than the global average of 0.4 per cent."

"• The number and percentage of persons aged 12 or older who were current users of hallucinogens in 2013 (1.3 million or 0.5 percent) were similar to those in 2012 (1.1 million or 0.4 percent), but were higher than in 2011 (1.0 million or 0.4 percent) (Figure 2.2)."

"• Slightly more than half (52.2 percent) of Americans aged 12 or older reported being current drinkers of alcohol in the 2013 survey, which was similar to the rate in 2012 (52.1 percent). This translates to an estimated 136.9 million current drinkers in 2013.

"• Nearly one quarter (22.9 percent) of persons aged 12 or older in 2013 were binge alcohol users in the 30 days prior to the survey. This translates to about 60.1 million people. The rate in 2013 was similar to the rate in 2012 (23.0 percent).

"• In 2013, heavy drinking was reported by 6.3 percent of the population aged 12 or older, or 16.5 million people. This percentage was similar to the rate of heavy drinking in 2012 (6.5 percent)."

"• An estimated 8.8 percent, or 10.1 million, of full-time workers reported past month heavy alcohol use (Figure 2.3 and Tables 2.2 and 2.3).

"• Past month heavy alcohol use was related to age. Among younger workers (18 to 25 years old), 16.3 percent reported past month heavy alcohol use compared with 10.4 percent of 26- to 34-year-olds, 8.1 percent of 35- to 49-year-olds, and 4.7 percent of 50- to 64-year-olds (Figure 2.3 and Table 2.2).

"• Males were three times as likely as females to be past month heavy alcohol users (12.3 vs. 4.1 percent) (Figure 2.4 and Table 2.2).

"• An estimated 10.1 percent of white adults reported heavy alcohol use in the past month. This was higher than the percentage among black adults (5.4 percent), Asian adults (2.9 percent), Hispanic adults (6.9 percent), and adults reporting two or more races (7.5 percent) (Figure 2.5 and Table 2.2).

"• Residents of noncore rural counties had a lower prevalence of past month heavy alcohol use (7.5 percent) compared with residents of micropolitan statistical area (9.2 percent), small MSA (9.8 percent), and large MSA (8.1 percent) counties (Table 2.3).

"• Workers with a college education had a lower prevalence of past month heavy alcohol use compared with those without a college education. Past month heavy alcohol use was lower among those with higher levels of education than those with less education (college graduate [6.7 percent] vs. less than high school [10.8 percent]) (Figure 2.6 and Table 2.3)."

"• In 2013, an estimated 66.9 million Americans aged 12 or older were current (past month) users of a tobacco product. This represents 25.5 percent of the population in that age range (Figure 4.1). Also, 55.8 million persons (21.3 percent of the population) were current cigarette smokers; 12.4 million (4.7 percent) smoked cigars; 8.8 million (3.4 percent) used smokeless tobacco; and 2.3 million (0.9 percent) smoked tobacco in pipes.

"• Between 2002 and 2013, past month use of any tobacco product among persons aged 12 or older decreased from 30.4 to 25.5 percent, and past month cigarette use declined from 26.0 to 21.3 percent (Figure 4.1). Past month cigar use decreased from 5.4 percent in 2002 to 4.7 percent in 2013. Rates of past month use of smokeless tobacco and pipe tobacco were similar in 2002 and 2013."

"Lifetime alcohol users aged 21 or older had a significantly higher rate of past year illicit drug use (13.7 percent) compared with lifetime nondrinkers (2.7 percent). In addition, lifetime alcohol users had significantly higher rates of past year use across all illicit drug categories, with the exception of inhalants (Table 1). Nonmedical use of pain relievers was the illicit drug used most often by lifetime nondrinkers, whereas lifetime alcohol users reported using marijuana most frequently."

"In 2002 and 2003, an estimated 88.2 percent of persons aged 21 or older (175.6 million) were lifetime alcohol users, whereas an estimated 11.8 percent (23.5 million) were lifetime nondrinkers. Over half of lifetime alcohol users (52.7 percent) had used one or more illicit drugs at some time in their life, compared to 8.0 percent of lifetime nondrinkers. Among persons who had used an illicit drug in their lifetime, the average age at first illicit drug use was 19 years for lifetime alcohol users, versus 23 years for lifetime nondrinkers."

"• As was the case in prior years, the level of alcohol use was associated with illicit drug use in 2013. Among the 16.5 million heavy drinkers aged 12 or older, 33.7 percent were current illicit drug users. Persons who were not current alcohol users were less likely to have used illicit drugs in the past month (4.3 percent) than those who reported current use of alcohol but no binge or heavy use (7.3 percent), binge use but no heavy use (18.5 percent), or heavy use of alcohol (33.7 percent).

"• Alcohol consumption levels also were associated with tobacco use in 2013. Among heavy alcohol users aged 12 or older, 53.1 percent smoked cigarettes in the past month compared with 16.2 percent of non-binge current drinkers and 15.5 percent of persons who did not drink alcohol in the past month. Smokeless tobacco use and cigar use also were more prevalent among heavy drinkers (12.1 and 15.4 percent, respectively) than among non-binge drinkers (2.0 and 3.9 percent) and persons who were not current alcohol users (2.0 and 1.8 percent)."

In 2015:
an estimated 117,865,000 people aged 12 or older in the US had tried marijuana at least once in their lifetimes.
an estimated 36,043,000 people aged 12 or older in the US had tried marijuana at least once in the past year.
an estimated 22,226,000 people aged 12 or older in the US had tried marijuana at least once in the past month.

Table: Marijuana Use in Lifetime, Past Year, and Past Month among Persons in the US Aged 12 or Older, by Demographic Characteristics: Number in Thousands

"Illicit drug use has increased across the country, dramatically so for opium, heroin and other opiates. In four years, the number of regular opium users in Afghanistan grew from 150,000 to approximately 230,000 ? a jump of 53 per cent. The numbers are even more alarming for heroin. In 2005, the estimate of regular heroin users in the country was 50,000, compared to approximately 120,000 users in 2009, a leap of 140 per cent. Overall, the annual prevalence of regular opiate use is estimated to be 2.7 per cent of the adult population1 (between 290,000 and 360,000 persons). Opium is by far the most commonly used opiate with an estimated prevalence of about 1.9 per cent of the adult population. Heroin prevalence is estimated to be about 1.0 per cent of the adult population and other opiates users2 are estimated to make up about 0.5 per cent of the adult population."

"The prevalence of heroin use is extremely difficult to estimate despite the fact that harm to society associated with heroin marketing and use is substantial. A disproportionate number of heroin users are part of the nonsampled populations in general prevalence surveys (persons with no fixed address, prison inmates, etc.) Also, heroin users are believed to represent less than one half of one percent of our total population, making heroin usage a relatively rare event. Sample surveys are not sensitive enough to measure rare events reliable. Data from the National Household Survey on Drug Abuse (which is considered to produce conservative estimates), indicated that 1.9 percent of blacks, 1.6 percent of Hispanics, and 1.4 percent of whites had ever tried heroin. As will be noted later in this report, the data available from hospital emergency rooms and from drug abuse treatment programs indicated that heroin use is a more serious problem among blacks than whites and Hispanics."

"Marijuana, the most widely used of the illicit drugs, did not show any significant change in annual prevalence this year in any of the three grades, nor in the three grades combined. After rising for several years, the annual prevalence of marijuana has more or less leveled out since about 2010.

"This year, 12 percent of 8th ­graders, 25 percent of 10th ­graders and 35 percent of 12th ­graders reported using marijuana at least once in the prior 12 months. Of more importance, perhaps, is their daily or near-­daily marijuana use (defined as smoking marijuana on 20 or more occasions in the past 30 days). These rates stand at 1.1 percent, 3.0 percent and 6.0 percent in 8th, 10th and 12th grades, respectively.

"In other words, one in every 16 or 17 high school seniors is smoking marijuana daily or near daily. These rates have changed rather little since 2010, but are from three-­to-­six times higher than they were at their low point in 1991.

"'The proportion of our young people smoking marijuana this frequently remains a matter of concern,' Johnston said.[2],[3]

"He notes that the percent of students who see regular marijuana use as carrying a great risk of harm has declined substantially since about 2005, and is still declining. Over the past 10 years, the percent seeing a great risk in regular marijuana use has fallen among 8th ­graders from 74 percent to 58 percent, among 10th ­graders from 66 percent to 43 percent and among 12th­graders from 58 percent to 32 percent."

"Globally, drug use is not distributed evenly. In general, the US had among the highest levels of use of all drugs. Much lower levels were observed in lower income countries in Africa and the Middle East, and lower levels of use were reported in the Asian locales covered."

"Although statistics on drug use in the United States are not fully reliable, the numbers available indicate that US consumption of cocaine and marijuana has been essentially stable for many years—although considerably reduced from its peak in the 1970s and 1980s. The data also show that, today, the United States consumes illegal substances at a rate some three times that of Europe—although the use of drugs in the EU continues to grow rapidly and a few countries actually consume more per capita than the United States. In both the United States and Europe, the wholesale and street prices of cannabis and cocaine have declined in the past several years, although reportedly their potency has increased and demand remains steady. Across the world, illicit drugs appear to be available at stable or declining prices. A recent EU Commission study concluded that global drug production and use remained largely unchanged during the period from 1998 through 2007."

"• Support for laws prohibiting consumption of marijuana in private has been in substantial decline since 1990 and has fallen by more than half from a high of 56% (in 1990) to 21% in 2019, the lowest level recorded by the survey. This trend is almost a mirror image of the pattern before 1990, when the proportion who believed private marijuana use should be prohibited more than doubled, from 25% in 1978 to its level of 56% in 1990 – also a dramatic shift. The trend for prohibition of marijuana use in public follows very closely the same overall pattern seen for private use, with support for prohibition of public use running about 30 percentage points higher in every year. In 2019 it was 49%, the second lowest level ever recorded by the survey (the lowest was in 2018 at 48%).

"• In 2019 the proportions of 12th grade students agreeing that use of LSD, heroin, and amphetamines in private should be prohibited by law continued their long declines and were near historic lows (Table 8-7). The decline has been weakest for heroin, which seems to have maintained its reputation as a very dangerous drug, and support for legal prohibitions against its use in private stood at 68% in 2019. Steeper declines have been apparent for LSD and amphetamines. For all three drugs, the trends for support of legal prohibitions against public use are similar to their trends for private use, although levels of support of legal prohibitions against public use are higher and are 60% or above in all years. Specifically, in 2019 all three drugs – LSD, heroin, and amphetamines – were at or near the lowest levels recorded by the survey.

"• The proportion of 12th graders who said smoking cigarettes “in certain specified public places” should be prohibited by law was 36% in 2019, a historic low. The proportion has dipped below the 40% level where it had hovered since 2013. In earlier years level of support hovered at around 45% since the 1980s and showed surprisingly little change given the steady decline in smoking prevalence over the course of the survey. Given recent widespread prohibitions of smoking in many public and private places, it is possible that the assumed definition of “certain specified public places” has expanded in the minds of many 12th graders.

"• Attitudes about the legality of drunkenness in public significantly declined in 2019 to 41%, a historic low. In the past decade the percentage of 12th grade students favoring prohibition of public drunkenness had varied within the narrow range of 46% to 50%. This historic low in 2019 joins historic lows in attitudes toward both smoking cigarettes and marijuana use in public, suggesting a growing, general opposition to legal prohibition of public drug use, at least for the most commonly used substances. For private drunkenness, support for a prohibition ranged from 19% to 23% over the past decade, and in 2019 registered at 21%."

"The information we have presented adds to the current literature on the impacts of decriminalization. It disconfirms the hypothesis that decriminalization necessarily leads to increases in the most harmful forms of drug use. While small increases in drug use were reported by Portuguese adults, the regional context of this trend suggests that they were not produced solely by the 2001 decriminalization. We would argue that they are less important than the major reductions seen in opiate-related deaths and infections, as well as reductions in young people’s drug use. The Portuguese evidence suggests that combining the removal of criminal penalties with the use of alternative therapeutic responses to dependent drug users offers several advantages. It can reduce the burden of drug law enforcement on the criminal justice system, while also reducing problematic drug use."

"Cannabis is perceived to be the easiest illicit substance to get hold of, with around one third of ESPAD students (32 %) rating cannabis as easily obtainable. More students in the Netherlands, Denmark, Czechia, Slovenia and Slovakia than in the other ESPAD countries perceived cannabis to be easily available (rates from 45 % to 51 %). The countries with the lowest perceived availability of cannabis were Kosovo (11 %), Ukraine (13 %), Romania (16 %) and North Macedonia (19 %). Boys were more likely than girls to consider cannabis to be easily available (ESPAD average: 34 % for boys versus 30 % for girls).

"Compared with cannabis, perceived availability was low for ecstasy (MDMA) (14 %), cocaine (13 %), amphetamine (10 %) and methamphetamine (8.5 %). These drugs were perceived to be more easily available in Bulgaria, Sweden and Denmark than elsewhere in Europe.

"The perceived availability of ecstasy was highest (over 20 %) in Slovakia, Czechia, Slovenia and the Netherlands, whereas for cocaine it was highest in Denmark and Ireland (22 % each). The countries with the lowest perceived availability of nearly all illicit drugs were Kosovo, Georgia and Romania.

"On average, 2.4 % of the ESPAD students reported having used cannabis for the first time at age 13 or younger. The highest proportions were found in France (4.5 %), Italy (4.4 %), Latvia (3.8 %), Cyprus (3.6 %) and Estonia (3.5 %). Rates of early onset of amphetamine/methamphetamine use were lower (ESPAD average: 0.5 %), with the highest proportion in Bulgaria (1.8 %). Boys were more likely than girls to have used cannabis or amphetamine/ methamphetamine at age 13 or younger. Similar results were found for early onset of ecstasy and cocaine use.

"The average prevalence of lifetime use of illicit drugs was 17 %, with considerable variation across ESPAD countries. It should be noted that this mainly relates to cannabis use (average lifetime prevalence of 16 %). The highest proportions of students reporting lifetime use of any illicit drug were found in Czechia (29 %), Italy (28 %), Latvia (27 %) and Slovakia (25 %). Particularly low levels (10 % or less) of lifetime illicit drug use were noted in Kosovo, Iceland, North Macedonia, Ukraine, Serbia, Sweden, Norway, Greece and Romania."

"Considering the ESPAD average, the lifetime prevalence of illicit drug use increased from 1995 to 2011 and has declined since then.

"Cannabis was the most widely used illicit drug in all ESPAD countries. On average, 16 % of students had used cannabis at least once in their lifetime. The countries with the highest prevalence of cannabis use were Czechia (28 %), Italy (27 %) and Latvia (26 %). The lowest levels of cannabis use (2.9-7.3 %) were reported in Kosovo, North Macedonia, Iceland and Serbia. On average, boys reported cannabis use to a larger extent than girls (18 % versus 13 %). This was the case in all countries except Bulgaria, Slovakia, Malta, the Netherlands and Czechia.

"Among all students who had used cannabis in the last 12 months (13 % of the total), the drug was used on average on about 10 occasions (9.9). In France, Italy, Serbia, Austria and Cyprus, cannabis was used once a month on average (12 or more occasions). The lowest average frequency of cannabis use was found in the Faroes (4.4 occasions). Overall, boys reported a higher frequency of cannabis use than girls.

"Overall, 7.1 % of the students had used cannabis in the last 30 days. A high variability was found among ESPAD countries, with the maximum rate observed in Italy (15 %) and the minimum in Kosovo (1.4 %). More boys than girls reported cannabis use in the last 30 days (boys 8.5 % versus girls 5.8 % on average), with statistically significant gender differences found in more than two thirds of ESPAD countries.

"To estimate the risk of cannabis-related problems, a core module, the CAST (Cannabis Abuse Screening Test) scale, was included in the ESPAD questionnaire. The prevalence of high-risk cannabis users (see the methodology section for a definition) ranged from 1.4 % to 7.3 % across countries, with an average of 4.0 %. Overall, the prevalence of high-risk cannabis users was higher among boys than girls (4.7 % versus 3.3 %). At the country level, statistically significant gender differences with higher rates among boys were found in 16 ESPAD countries.

"Trends in cannabis use indicate a general increase in both lifetime and last-30-day use between 1995 and 2019, from 11 % to 16 % and from 4.1 % to 7.4 %, respectively. Both prevalence rates reached their highest levels in 2011, with lifetime use slightly decreasing thereafter and current use levelling off.

"On average, 1-2 % of the ESPAD students had ever used an illicit drug other than cannabis at least once. After cannabis, the most widely used illicit drugs were ecstasy (MDMA), LSD (lysergic acid diethylamide) or other hallucinogens, cocaine and amphetamine. Lifetime prevalence rates for methamphetamine, crack, heroin and GHB (gammahydroxybutyrate) were lower than those for the other illicit drugs (about 1.0 % on average). At the country level, higher rates of lifetime use were found in Estonia and Latvia (lifetime use of ecstasy, LSD or other hallucinogens of about 5.0 %)."

"Illicit drug use in 2011 varied by the educational status of adults aged 18 or older, with the rate of current illicit drug use lower among college graduates (5.4 percent) than those with some college education (10.4 percent), high school graduates (8.9 percent), and those who had not graduated from high school (11.1 percent)."

"In 2010, there were 50.5 million Hispanics in the United States, composing 16 percent of the total population .... Between 2000 and 2010, the Hispanic population grew by 43 percent—rising from 35.3 million in 2000, when this group made up 13 percent of the total population.⁹ The Hispanic population increased by 15.2 million between 2000 and 2010, accounting for over half of the 27.3 million increase in the total population of the United States."
^{According to the 2010 Census, "'Hispanic or Latino' refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race."}

"In the 2010 Census, 97 percent of all respondents (299.7 million) reported only one race (see Table 1).¹⁰ The largest group reported White alone (223.6 million), accounting for 72 percent of all people living in the United States.¹¹ The Black or African-American alone population was 38.9 million and represented 13 percent of the total population.¹² There were 2.9 million respondents who indicated American Indian and Alaska Native alone (0.9 percent). Approximately 14.7 million (about 5 percent of all respondents) identified their race as Asian alone."

"Among 50-year-old high school graduates in 2012, we estimate that about three quarters (74%) have tried marijuana, and that about two thirds (64%) have tried an illicit drug other than marijuana. (These estimates are adjusted to correct for panel attrition, as described in chapter 4 of Volume II.)

"Their current behavior is far less extreme than those statistics might suggest, but it is not by any means negligible. One in eight (12%) indicates using marijuana in the last 12 months, and one in ten (10%) indicates using any other illicit drug in the same period. Their past-month prevalence rates are lower—7.3% and 6.2%, respectively, for marijuana and any other illicit drug. About 1 in 43 (2.3%) is a current daily marijuana user, though substantially more indicate that they have used marijuana daily at some time in the past."

"• Among adults aged 50 to 64, the rate of current illicit drug use increased from 2.7 percent in 2002 to 6.0 percent in 2013. For adults aged 50 to 54, the rate increased from 3.4 percent in 2002 to 7.9 percent in 2013 (Figure 2.10). Among those aged 55 to 59, the rate of current illicit drug use increased from 1.9 percent in 2002 to 5.7 percent in 2013. Among those aged 60 to 64, the rate of current illicit drug use increased from 1.1 percent in 2003 and 2004 to 3.9 percent in 2013."

(Baby Boomers) "In 2007, the rate of past year use in this age group [persons aged 50 to 59] was 9.4 percent for any illicit drug, 5.7 percent for marijuana, and 4.0 percent for nonmedical use of prescription drugs. Analyses show that the observed increases are driven primarily by the aging of the baby boom cohort, which has a much higher lifetime illicit drug use rate than earlier cohorts, representing an increasing proportion of persons aged 50 to 59. Less than 3 percent of past year users initiated drug use at ages 50 to 59. Almost 90 percent of past year users initiated drug use before age 30, and many have been continuing users over the years."

Substance Use in the Military

"The prevalence of any reported illicit drug use (including prescription drug misuse) during the past 30 days declined sharply from 28% in 1980 to 3% in 2002. In 2005, the prevalence of illicit drug use for the past 30 days was 5% and in 2008 it was 12%. Improved question wording in 2005 and 2008 may partially account for the higher observed rates, which are largely attributable to reported increases in misuse of prescription pain medications (see Section 3.3.2 for additional discussion). Because of wording changes, data from 2005 and 2008 are not comparable to data from prior surveys and are not included as part of the trend line. An additional line from 2002 to 2008 shows estimates of illicit drug use excluding prescription drug misuse. As shown, those rates were very low (2% in 2008) and did not change across these three iterations of the survey."

"Given that illicit drug use is inconsistent with Army Values, one would not expect the presence of multiple and serial drug offenders in the Army. Data for FY 2001 – FY 2009 indicate otherwise.⁷⁶ Drug testing results reveal that of the total number of Soldiers tested, 3.5% (58,687 of 1,662,004) were positive for illicit drug use (see Table 7, page 50). That includes Soldiers who tested positive one, two or three or more times. When separated into these specific categories, 36,470 (62%) were first time positives, 11,828 (20%) were multiple, and 10,389 (18%) were serial offenders."

"• Among current drinkers, 39.6% reported binge drinking in the past month, with the Marine Corps reporting the highest prevalence of binge drinking (56.7%), and the Air Force reporting the lowest prevalence (28.1%).
"• When examining levels of drinking across all services, 9.9% were classified abstainers, 5.7% were former drinkers, and 84.5% were current drinkers; 58.6% of all personnel were classified as infrequent/light drinkers, 17.5% were moderate drinkers, and 8.4% were classified as heavy drinkers.
"• Heavy drinkers were more often in the Marine Corps (15.5%), had a high school education or less (12.6%), 21-25 years old (13.2%), unmarried (11.9%), and stationed OCONUS (9.9%).
"• In general, active duty personnel who were heavy drinkers, initiated alcohol use at earlier ages, or drank at work more often reported higher work-related productivity loss, serious consequences from drinking, began drinking at older ages, or did not drink at work.
"• Across all drinking levels, 11.3% of active duty personnel were classified as problem drinkers (AUDIT ≥), with 58.4% of heavy drinkers considered problem drinkers compared to 22.6% of moderate drinkers and 3.5% of infrequent/light drinkers."

"While the overall illicit drug use rate is holding constant, the number of MRO reviews is increasing (includes legitimate prescription drug use and positive UAs for other pharmaceutical drugs; see Figure 15, page 54). As previously noted, current policy governing prescription drug use may be masking illicit drug use due to open-ended prescriptions. Overall use of amphetamines (including both legal and illegal) is growing at a rate of 2.8 percent per year for all COMPOS. This means that by the end of next year it is expected that there will be over 5,000 MRO [Medical Regulating Officer] reviewable positive tests for amphetamines alone. Among the street drugs, marijuana is increasing significantly within the National Guard population. In fact, if we look at the rate of THC positives over the last four years, it is predicted that over 7,500 Guard Soldiers will test positive for THC this year."

"For the DoD services, the percentage of military personnel who smoked cigarettes in the past 30 days decreased significantly from 51% in 1980 to 30% in 1998. It increased significantly from 1998 (30%) to 2002 (34%), and while not showing significant declines in 2005 (32%) and in 2008 (31%), has been slowly trending downward since 2002."

"In 2008, 47% of all DoD services personnel were binge drinkers. For all DoD services, binge drinking increased between 1998 and 2008 but was stable between 2005 and 2008.
"For each service, binge drinking also increased overall between 1998 and 2008. Between 2005 and 2008, binge drinking rates significantly increased for the Navy and the Air Force and were stable for the Army and the Marine Corps."

"Military personnel aged 18 to 25 showed significantly higher rates of heavy drinking (26%) than did civilians (16%).
"Likewise, military personnel aged 26 to 35 showed higher rates of heavy drinking (18%) than did their civilian counterparts (11%). For those aged 36 to 45, this rate was slightly higher for military personnel than civilians (10% vs. 8%) though this difference did not reach statistical significance.
"Among those aged 46 to 64, military personnel exhibited lower rates of heavy alcohol use (4%) than did civilians (9%).
"Across all age groups, military personnel showed significantly higher rates of heavy drinking (20%) than did civilians (14%)."

(Drug Use by Veterans, 2003) "In 2003, there were an estimated 25 million veterans comprising roughly 11.5 percent of the 217 million non-institutionalized civilians aged 17 or older in the United States."
"An estimated 3.5 percent of veterans used marijuana in the past month compared with 3.0 percent of their nonveteran counterparts in 2003"
"Heavy use of alcohol was more prevalent among veterans than comparable nonveterans, with an estimated 7.5 percent of veterans drinking heavily in the past month compared with 6.5 percent of their nonveteran counterparts."
"Using criteria from the DSM-IV, an estimated 2.6 percent of veterans were dependent on alcohol in the past year (Figure 2). A much smaller proportion of veterans (0.9 percent) was dependent on illicit drugs in the past year."
"An estimated 0.8 percent of veterans received specialty treatment4 for a substance use disorder (alcohol or illicit drugs) in the past year compared with 0.5 percent of their nonveteran counterparts (Figure 3). An estimated 2.8 percent of veterans were dependent on illicit drugs or alcohol but did not receive treatment in the past year.5 A similar proportion of comparable nonveterans went untreated."

Sociopolitical Research

"There were little or no differences in the probability of employment by lifetime alcohol and drug use patterns. Men who had an alcohol disorder at some point in their life were equally likely as men who had never drunk alcohol to be currently employed (.91) and only slightly less likely than moderate alcohol users (.91 vs. .92, p=.09). Similarly, men who had a drug disorder at some point in their life were somewhat less likely (.90 vs. 92, p=.07) to be currently employed, but there was no statistically difference between moderate drug users and non-users. Differences among men by their current (last 12 months) alcohol and, especially, drug use patterns were greater. Current moderate alcohol drinkers were actually more likely than those who had not drunk alcohol in the last year to be employed (.93 vs. 91), while those with a current alcohol problem were less likely to be employed than either moderate or nondrinkers (.89). In contrast to moderate alcohol users, current moderate drug users were less likely to be employed than nonusers (.88 vs. .92). Men with a current drug problem were substantially less likely to be employed (.82) than either moderate or non drug users."

"In conclusion, patterns of prescription drug misuse among high-risk young adults in LA and NY appear to conform to and be shaped by differences in local markets for illicit drugs in each city. Our findings indicate that current misuse of prescription drugs in both cities encompasses a broad range of practices, such as sniffing, injecting, polydrug use, and drug substitution, and involves frequent misuse of illicit substances. Initiation into prescription drug misuse was often preceded by being prescribed one or more types of prescription drugs, which was then followed by initiating illicit drugs with similar psychotropic effects."

(Use Unrelated to Enforcement) "Opponents of drug policy reform commonly argue that drug use would increase if health-based models were emphasized over drug law enforcement,¹⁴ but we are unaware of any research to support this position. In fact, a recent World Health Organization study demonstrated that international rates of drug use were unrelated to how vigorously drug laws were enforced, concluding that 'countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones.'¹⁵"

"In conclusion, this study found that chronic drug use was significantly related to employment status for men and women. On the other hand, male chronic drug users were less likely to participate in the labor force, but no significant relationship existed between chronic drug use and labor force participation for females. Perhaps the most important finding of this study, however, was the lack of any significant relationships between nonchronic drug use, employment, and labor force participation. An implication of this finding is that employers and policy makers should focus on problematic drug users in the same way that they focus on problematic alcohol users."

"In 2010, mental and substance use disorders accounted for 183.9 million DALYs [Disability-Adjusted Life Years] (95% UI 153.5 million–216.7 million), or 7.4% (6.2–8.6) of all DALYs worldwide. Such disorders accounted for 8.6 million YLLs [Years of Life Lost] (6.5 million–12.1 million; 0.5% [0.4–0.7] of all YLLs) and 175.3 million YLDs [Years Lived with Disability] (144.5 million–207.8 million; 22.9% [18.6–27.2] of all YLDs). Mental and substance use disorders were the leading cause of YLDs worldwide. Depressive disorders accounted for 40.5% (31.7–49.2) of DALYs caused by mental and substance use disorders, with anxiety disorders accounting for 14.6% (11.2–18.4), illicit drug use disorders for 10.9% (8.9–13.2), alcohol use disorders for 9.6% (7.7–11.8), schizophrenia for 7.4% (5.0–9.8), bipolar disorder for 7.0% (4.4–10.3), pervasive developmental disorders for 4.2% (3.2–5.3), childhood behavioural disorders for 3.4% (2.2–4.7), and eating disorders for 1.2% (0.9–1.5). DALYs varied by age and sex, with the highest proportion of total DALYs occurring in people aged 10–29 years. The burden of mental and substance use disorders increased by 37.6% between 1990 and 2010, which for most disorders was driven by population growth and ageing."

"In conclusion, our results suggest that participation in the use of both licit and illicit drugs is price sensitive. Participation is sensitive to own prices and the price of the other drugs. In
particular, we conclude that cannabis and cigarettes are complements, and there is some evidence to suggest that cannabis and alcohol are
substitutes, although decriminalization of cannabis corresponds with higher alcohol use. Alcohol and cigarettes are found to be complements.
"The results also show that the liberalized legal status of cannabis in South Australia coincides with higher cannabis participation on average over the period under investigation. In South Australia, where possession of small amounts of cannabis is no longer a criminal offence, the probability of use is estimated to be 2.0 percentage points higher than elsewhere based on the pooled sample of data. Further investigation revealed that although participation increased in South Australia shortly after the liberalization of the cannabis laws, the effect of decriminalization was transitory and had disappeared in seven years. In addition, our results indicate that the increase in participation was due to individuals over 30 delaying giving up cannabis use as a result of its changed legal status, not an increase in use
by younger people. This finding provides an explanation of why US studies based on youth fail to find that decriminalization has an impact on
the probability of cannabis use, while studies based on adults and youth, or just adults, do find a positive association between decriminalization and participation in cannabis use."

"Although residents of disadvantaged neighborhoods, neighborhoods with high concentrations of minorities, and neighborhoods with high population densities reported much higher levels of visible drug sales, they reported only slightly higher levels of drug use, along with somewhat higher levels of drug dependency. This finding indicates that conflating drug sales with use, so that poor and minority areas are assumed to be the focus of the problem of drug use, is plainly wrong. The finding is based on the data collected across 41 sites, including city and suburban (but not rural) areas in all regions."

"We conclude that there is an association between substance use and occupational injury. This association is stronger for males and in certain industries, such as manufacturing and construction, and may also be stronger for younger workers, though future research is needed on this last point. The proportion of injuries caused by substance use, however, is relatively small. Instead, there is mounting evidence that harmful substance use is one of a constellation of behaviors exhibited by certain individuals who may avoid work-related safety precautions and take greater work-related risks. Thus, we suspect that it is more likely that risk-taking dispositions, often termed deviance proneness, and other omitted factors can explain most empirical associations between substance use and injuries at work."

"Legal and illegal use of drugs was most strongly associated with age, sex, and income. Higher income was associated with a greater likelihood of drug use for all drug types examined, which is perhaps not surprising given that drug use requires disposable income. Relationship status was linked to illegal (but not legal) drug use: both cocaine and cannabis use were more likely among persons who had never been married or previously been married."

"Although serious drug use is slightly more prevalent in poor minority neighborhoods than elsewhere, the major problem for disadvantaged neighborhoods is drug distribution. These communities are victims not only of their own drug abuse but also of a criminal drug market that serves the entire society. The market establishes itself in disadvantaged communities in part because of the low social capital in these neighborhoods. The drug economy further erodes that social capital."

"The use of drugs seems to be a feature of more affluent countries. The US, which has been driving much of the world’s drug research and drug policy agenda, stands out with higher levels of use of alcohol, cocaine, and cannabis, despite punitive illegal drug policies, as well as (in many US states), a higher minimum legal alcohol drinking age than many comparable developed countries. The Netherlands, with a less criminally punitive approach to cannabis use than the US, has experienced lower levels of use, particularly among younger adults. Clearly, by itself, a punitive policy towards possession and use accounts for limited variation in nation level rates of illegal drug use."

"Because the impacts of problem drug users are largely hidden, and also because their number is actually relatively small (approximately 330,000; Hay et al., 2008),²² people’s understanding of problem drug use tends to come from remote sources – the media (including the internet, television, films, magazines and books) and anecdote – rather than from direct experience. This provides fertile ground for the growth of myths and stereotypes: for example, the prevalent belief in instant addiction and the myth of the drug dealer offering free drugs at the school gates."

"Some scientists have recently turned to the sewer to develop a more accurate estimate of drug use. They examine tiny samples of raw sewage for the presence of illicit drugs and their metabolites in a science known as sewer epidemiology.⁴ These samples are essentially a diluted urine test collected from an entire community,⁵ making them akin to a “community urinalysis.”⁶ The basic science is simple: nearly every drug ingested into the body is eventually excreted and finds its way into the sewer system, allowing scientists to profile a community’s drug use based on objective data."

"Monitoring the Future (MTF) is designed to give sustained attention to substance use among the nation’s youth and adults. It is an investigator-initiated study that originated with and is conducted by a team of research professors at the University of Michigan’s Institute for Social Research. Since its onset in 1975, MTF has been continuously funded by the National Institute on Drug Abuse — one of the National Institutes of Health — under a series of peer-reviewed, competitive research grants. The 2014 survey, reported here, is the 40th consecutive survey of 12th-grade students and the 24th such survey of 8th and 10th graders.

"MTF contains ongoing series of national surveys of both American adolescents and adults. It provides the nation with a vital window into the important but largely hidden problem behaviors of illegal drug use, alcohol abuse, tobacco use, anabolic steroid abuse, and psychotherapeutic drug abuse. For four decades MTF has helped provide a clearer view of the changing topography of these problems among adolescents and adults, a better understanding of the dynamics of factors that drive some of these problems, and a better understanding of some of their consequences. It has also given policymakers, government agencies, and nongovernmental organizations (NGOs) in the field some practical approaches for intervening."

"Marijuana use declined in the early 2000s, but subsequently rebounded before leveling in the past couple of years. In 2014 the percentage of youth who used marijuana in the past year among students in 12th, 10th, and 8th grade was 35.1%, 27.3%, and 11.7%, respectively.

"It is important to note that 8th grade students were the first to show the two major shifts in marijuana prevalence — an increase at the start of the 1990s and a decrease by the end of the 1990s. As mentioned above, this suggests that 8th graders may be the most immediately responsive to changing influences in the larger social environment. The lag in the decline in the later grades likely reflects some cohort effects (i.e., lingering effects of changes in use that occurred when the students were in lower grades).

"Levels of annual marijuana use today are considerably lower than the historic highs observed in the late 1970s, when more than half of U.S. 12th graders had used marijuana in the past year. This high point marked the pinnacle of a rise in marijuana use from relatively negligible levels before the 1960s.²

"Important changes in young people’s attitudes and beliefs about marijuana use have occurred over the study period, and these changes can account for much of the long-term decline in use, as well as the increase in use during the 1990s drug relapse. Chapter 8 contains a more thorough discussion of this issue.

"• Figure 5-4a and Table 5-5d provide trends in daily marijuana use. These trends depart somewhat from the typical pattern seen for drug use because, among 12th graders, today’s level of use is actually higher than it was at the end of the 1990s relapse period. Although daily use of marijuana declined somewhat in 2014 as compared to the previous year, the average level since 2010 (i.e., 2011–2014 combined) is the highest recorded in the past two decades. (See Chapter 10 for additional information on the cumulative amount of daily marijuana use among 12th graders. It shows that the proportion using marijuana daily for a month or more at any time in the past is considerably higher than the proportion reporting daily marijuana use during just the past month.) The overall trends follow a similar pattern in 12th, 10th, and 8th grade, and in 2014 prevalence levels of daily marijuana use were 5.8%, 3.4%, and 1.0%, respectively. About one in every 17 twelfth-grade high school students in 2014 was a daily or near-daily marijuana user.

"Still, the percentage of youth using marijuana on a daily basis today is substantially lower than its peak in the late 1970s, when it reached a high of 10.7% among 12th grade students. As we will discuss in Chapter 8, we think much of the decline from this peak is attributable to a very substantial increase in teens’ concerns about possible adverse effects from regular use and to a growing perception that peers disapproved of marijuana use, particularly regular use. The recent surge in daily marijuana use since 2009 among 12th-grade students tracks with concurrent, decreasing levels of perceived harmfulness and disapproval of regular marijuana use.

"• In 2014 marijuana use showed a one-year, slight decline in lifetime, annual, thirty-day, and daily use in all three grades. This finding is unexpected in light of the positive publicity marijuana has received in recent years prior to the data collection in 2014, with several states allowing medical marijuana use and two states (Colorado and Washington) legalizing recreational use for adults. Further, perceived risk of marijuana use among adolescents has declined in recent years (discussed in more detail in Chapter 8), which also supports an expectation for an increase in marijuana use this year. The study results point to the need for further qualitative and quantitative research to analyze why marijuana use has not increased in the last two or three years as expected."

"Prevalence of cigarettes is generally higher than for any of the illicit drugs, except for marijuana. More than one fifth (22.3%) of 12th graders reported having tried cigarettes at some time, and one in seventeen (5.7%) smoked in the prior 30 days. Even among 8th graders, one tenth (10%) reported having tried cigarettes and 2.3% reported smoking in the prior 30 days. Among 10th graders, 14.2% reported having tried cigarettes, and 3.4% reported smoking in the prior 30 days. The percentages reporting smoking cigarettes in the prior 30 days are actually far lower in all three grades in 2019 than the percentages reporting using marijuana in the prior 30 days: 2.3% for cigarettes versus 6.6% for marijuana in 8th grade; 3.4% versus 18.4% in 10th grade; and 5.7% versus 22.3% in 12th grade. These numbers reflect mostly the considerable, steady decline in cigarette use that has occurred over the past two decades. Among 8th, 10th and 12th graders, lifetime prevalence of marijuana use in 2019 was also higher than lifetime prevalence of cigarette use. (Annual prevalence of cigarette use is not assessed.)"

"Any prescription drug misuse includes use of narcotics, sedatives, tranquilizers, and/or amphetamines without medical supervision. It has been of considerable public health concern in recent years, because most of these drugs showed a substantial increase in use in the 1990s, which then continued into the first decade of the 2000s, when many of the illegal drugs already were in decline.

"Only 12th-graders report on their use of all of these drugs; they show a statistically significant decline between 2013 and 2014, from 16 percent to 14 percent, saying that they used one or more of these prescription drugs in the 12 months prior to the survey. The gradual turnaround began after 2005, when 17 percent indicated misuse of any of these drugs.

"'It's not as much progress as we might like to see, but at least the number of students using these dangerous prescription drugs is finally declining,' Johnston said.

"Narcotic drugs other than heroin—among the most dangerous of the prescription drugs—have been declining in use by 12th-graders since 2009, when 9 percent indicated using them without medical supervision in the prior 12 months. Their use continued to drop significantly, from 7 percent in 2013 to 6 percent in 2014. Use of these drugs is reported only for 12th grade; students are reporting that these drugs are increasingly difficult to obtain.

"Use in the prior 12 months of the specific narcotic analgesic OxyContin also declined this year, significantly so in 8th grade. OxyContin use reached a recent peak among adolescents around 2009 and use has declined since then in all three grades. The 2014 reports of use in the past 12 months stand at 1.0 percent, 3.0 percent and 3.3 percent in grades 8, 10 and 12, respectively."

"Most 12th graders felt that they would be little affected personally by the legalization of either the sale or the use of marijuana. Over half (56%) of the respondents said that they would not use the drug even if it were legal to buy and use, while others indicated they would use it about as often as they do now (15%) or less often (1.5%). Only 9% said they would use it more often than they do at present, while 10% thought they would try it. Another 9% said they did not know how their behavior would be affected if marijuana were legalized. Still, this amounts to 19% of all seniors, or about one in five, who thought that they would try marijuana, or that their use would increase, if marijuana were legalized."

"• Substantial differences were found in perceived availability of the various drugs. In general, the more widely used drugs are reported to be available by higher proportions of the age group, as would be expected (see Tables 9-6, 9-7, and 9-8). Also, older age groups generally perceive drugs to be more available. For example, in 2013, 39% of 8th graders said marijuana would be fairly easy or very easy to get (which we refer to as 'readily available'), versus 70% of 10th graders and 81% of 12th graders. In fact, compared to 8th graders, the proportion of 12th graders indicating that drugs are available to them is two to four times as high for other drugs included in the study and five times as high for narcotics other than heroin. (Tranquilizers, on the other hand, are reported as only a little less available by 8th graders.) Both associations are consistent with the notion that availability is largely attained through friendship circles. (A section in Chapter 10 documents where 12th graders obtain prescription drugs that are not medically prescribed, and friends clearly are the leading source.) The differences among age groups may also reflect less willingness and/or motivation on the part of those who deal drugs to establish contact with younger adolescents. Because many inhalants — such as glues, butane, and aerosols — are universally available, we do not ask about their availability. See Table 9-8 for the full list of drugs included in the questions for 12th graders; a few of these drugs were not asked of the younger students (see Tables 9-6 and 9-7).

"• Measures on the availability of cigarettes are not included in the 12th-grade questionnaires because we have assumed that they are almost universally available to this age group. However, data on this measure are collected from 8th and 10th graders, which clearly show that cigarettes are readily available to most of them. In 2013, 50% of 8th graders and 71% of 10th graders thought that cigarettes would be fairly easy or very easy for them to get if they wanted some.

"• The great majority of teens also see alcohol as readily available: In 2013, 56% of 8th graders, 77% of 10th graders, and 90% of 12th graders said it would be fairly easy or very easy to get."

"Overall, these data reveal that, while use of individual drugs (other than marijuana) may fluctuate widely, the proportion using any of them is much more stable. In other words, the proportion of students prone to using such drugs and willing to cross the normative barriers to such use changes more gradually. The usage rate for each individual drug, on the other hand, reflects many more rapidly changing determinants specific to that drug: how widely its psychoactive potential is recognized, how favorable the reports of its supposed benefits are, how risky its use is seen to be, how acceptable it is in the peer group, how accessible it is, and so on."