Symptoms of Substance Dependence Associated with Use of Cigarettes, Alcohol, and Illicit Drugs -- United States, 1991-1992

Each year in the United States, approximately 400,000 deaths result from cigarette smoking, 100,000 from misuse of alcohol, and 20,000 from use of illicit drugs (1). Many of the adverse health effects associated with the use of tobacco, alcohol, and illicit drugs result from long-term use caused by substance dependence (i.e., addiction) (2,3) -- a cluster of cognitive, behavioral, and physiological symptoms indicating sustained psychoactive substance use despite substance-related problems (4). In addition, substance dependence is characterized by repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior. Nicotine is the psychoactive substance in cigarettes and other forms of tobacco that accounts for the addictive properties of tobacco (2). In addition to tobacco, other potentially addictive substances include alcohol, marijuana, and cocaine (3). To assess the prevalence of selected indicators of substance dependence among the U.S. population, CDC and the National Institute on Drug Abuse analyzed data from the National Household Survey on Drug Abuse (NHSDA) (5) for 1991-1992. The findings in this report suggest that a symptom of substance dependence is more likely to be reported by persons who smoke cigarettes and persons who use cocaine than by persons who use alcohol or marijuana.

NHSDA is a household survey of a nationally representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 12 years. Data from the 1991 and 1992 surveys were combined (n=61,426) to estimate the prevalence of daily use of cigarettes, alcohol, marijuana, and cocaine for greater than or equal to 2 consecutive weeks during the preceding 12 months; attempts to reduce use; and four indicators of substance dependence among persons aged greater than or equal to 12 years who reported having used one of the four substances one or more times during the 30 days preceding the survey. Indicators of dependence for other substances (including heroin, tranquilizers, sedatives, analgesics, and inhalants) were not analyzed because the numbers of persons who reported use were too small to calculate reliable estimates.

Information about the indicators of dependence was based on responses to four questions; persons who reported current use * of cigarettes, alcohol, marijuana, or cocaine were asked whether, during the 12 months preceding the survey, they 1) "felt {they} needed or were dependent on {the substance}," 2) "needed larger amounts to get the same effect," 3) "felt unable to cut down on {their} use even though {they} tried," and 4) "had withdrawal symptoms, that is, felt sick because {they} stopped or cut down on {their} use." The analysis of "unable to cut down" and "felt sick" was restricted to persons who reported trying to reduce their substance use during the preceding 12 months. Data were adjusted for nonresponse and weighted to provide national estimates. Standard errors were calculated by using SUDAAN (6).

Of the 61,426 total NHDSA participants during 1991-1992, use of cigarettes, alcohol, marijuana, or cocaine during the 30 days preceding the survey was reported by 14,688 (26.6%), 27,814 (49.4%), 3904 (4.6%), and 821 (0.8%) persons, respectively (Table_1, page 837). Daily use of these substances for greater than or equal to 2 consecutive weeks during the 12 months preceding the survey was reported by 78.4% of persons who smoked cigarettes, and by 22.6%, 13.8%, and 12.4% of those who used marijuana, alcohol, and cocaine, respectively. Cigarette smokers were more likely than persons who used the other substances to report having tried to cut down, and were approximately twice as likely as persons who used alcohol, marijuana, or cocaine to report having been unable to cut down (Table_1, page 837). Cigarette smokers were more likely than users of the other substances to report feeling dependent on the substance or feeling sick when they stopped or cut down on its use. Cigarette smokers (75.2%) were more likely to report one of the four symptoms of dependence than were persons who used cocaine (29.1%), marijuana (22.6%), or alcohol (14.1%).

To compare data for more frequent users, the analysis was restricted to persons who had used these substances daily for greater than or equal to 2 consecutive weeks during the 12 months preceding the survey. Of the 47,227 current substance users, 14,615 (30.9%) reported daily use. Among these persons, those who smoked cigarettes were more likely than those who used alcohol or marijuana to report having been unable to cut down (Table_1, page 837). Persons who had used cocaine daily were more likely than persons who had used cigarettes, alcohol, or marijuana to report feeling a need for more of the substance to get the same effect. Persons who were daily cigarette smokers were more likely than persons who used alcohol, marijuana, or cocaine daily to report feeling dependent on the substance and were more likely than daily users of alcohol or marijuana to report feeling sick when they stopped or cut down. Among persons who had used any of the four substances every day for greater than or equal to 2 consecutive weeks, those who smoked cigarettes (90.9%) and those who used cocaine (78.9%) were more likely to report a symptom of addiction than were persons who used alcohol (48.1%) or marijuana (58.8%).

To determine whether the prevalence of reported symptoms varied for different measures of frequency of use, the analysis was further restricted to persons who reported that, on average, they used each substance on a daily or weekly basis during the 12 months preceding the survey. Although the prevalance estimates varied within each category of substance use, the relative ranking of the substances by frequency of symptoms of dependency remained constant.

Reported by: J Henningfield, Clinical Pharmacology Research Br, Addiction Research Center, National Institute on Drug Abuse. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report suggest that persons who smoked cigarettes and persons who used cocaine were more likely than those who used alcohol or marijuana to report a symptom of substance dependence after controlling for frequency of use. The high level of dependency associated with cigarette smoking may account, in part, for the low success rate for attempts to quit smoking (only 2.5% of smokers successfully quit each year) even though most smokers report wanting to quit smoking (7). In addition, a high proportion (73%) of adolescents who smoke but who intended to quit smoking in 5-6 years were still smoking 5 years later (8).

The findings in this report are subject to at least three limitations. First, the four NHSDA indicators do not provide a comprehensive measure of substance dependence because not all symptoms of the withdrawal syndromes characteristic of each substance were included. As a result, the proportion of persons who reported at least one indicator of substance dependence may be underestimated. Second, the categories of substance use were not mutually exclusive, and possible interactions experienced by users of multiple substances were not examined. Finally, these findings are based on self-reported data, and self-perception of substance dependence was not validated; however, self-reported symptoms of nicotine dependence have been confirmed previously by observer rating (2).

Although the severity of dependence can be estimated by the number of symptoms reported for persons using a particular psychoactive substance (4), criteria have not been developed to enable comparisons of the severity of dependence of different substances (9). Therefore, the findings in this report cannot be interpreted to indicate that nicotine produces more severe addiction than cocaine, marijuana, or alcohol. In addition, differences in the patterns of use of these substances and in the development of dependency may reflect their availability and accessibility: because cigarettes and alcohol are legal for adults, they are more available and accessible than marijuana and cocaine. Other factors that may account for some of these differences include price, advertising and promotion, social pressure, regulations, sanctions, and pharmacologic characteristics (9).

The use of cigarettes, alcohol, and illicit drugs all result in excess dependence, morbidity, and mortality and in substantial economic costs (1,3,10). Public health interventions that decrease the availability and social acceptability of tobacco use assist in reducing the initiation of use and the development of nicotine addiction (8). These approaches include reducing illegal sales of tobacco to minors, increasing the real price of tobacco products, restricting tobacco advertising and promotion targeted toward minors, and conducting educational and advertising campaigns that "deglamorize" tobacco use. School- and community-based educational interventions can help prevent tobacco initiation (8) and the use of alcohol and other substances (10). In addition, improved access to substance-dependence treatment programs may help reduce the health burden resulting from the use of tobacco, alcohol, and illicit drugs (10).

References

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.

2. CDC. The health consequences of smoking: nicotine addiction -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (CDC)88-8406.

3. Schuster CR, Kilbey MM. Prevention of drug abuse. In: Maxcy KF, Rosenau MJ, Last JM, (eds). Maxcy-Rosenau-Last public health and preventive medicine. 13th ed. East Norwalk, Connecticut: Appleton and Lange, 1992.

4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.

5. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: population estimates, 1992. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, 1993; DHHS publication no. (SMA)93-2053.

6. Shah BV. Software for survey data analysis (SUDAAN), version 5.5 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

7. CDC. Smoking cessation during previous year among adults -- United States, 1990 and 1991. MMWR 1993;42:504-7.

8. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

9. Henningfield JE, Cohen C, Slade JD. Is nicotine more addictive than cocaine? Br J Addict 1991;86:565-9.

10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

• Used one or more times during the 30 days preceding the survey.

TABLE 1. Percentage of respondents * who reported current + substance use during the 12 months preceding the survey, by selected indicators
of dependence & -- United States, National Household Survey on Drug Abuse, 1991-1992
==============================================================================================================================================


                 No.       Used daily       Tried to        Unable to       Felt need         Felt          Felt sick           >=1
             persons who  for >=2 weeks     cut down         cut down       for more        dependent      when stopped     indicator @
Category/     reported   ---------------  -------------   -------------   -------------   -------------   --------------   ---------------
 Substance       use      %  (95% CI **)  %  (95% CI)      %  (95% CI)     %  (95% CI)     %  (95% CI)      %  (95% CI)      %  (95% CI)
----------------------------------------------------------------------------------------------------------------------------------------------
All
 respondents ++
 Cigarettes     14,688   78.4  (+/-1.7)   64.4 (+/- 1.7)  76.6 (+/- 1.8)  14.0 (+/- 1.2)  68.9 (+/- 1.7)  34.9 (+/- 2.0)   75.2  (+/- 1.6)
 Alcohol        27,814   13.8  (+/-0.9)   25.1 (+/- 1.0)  39.8 (+/- 2.5)   5.8 (+/- 0.5)   6.6 (+/- 0.6)   8.8 (+/- 1.4)   14.1  (+/- 0.8)
 Marijuana       3,904   22.6  (+/-2.5)   31.7 (+/- 2.5)  33.6 (+/- 4.2)  10.3 (+/- 1.6)  12.2 (+/- 1.6)   9.8 (+/- 2.6)   22.6  (+/- 2.1)
 Cocaine           821   12.4  (+/-4.0)   39.7 (+/- 7.1)  38.4 (+/-10.8)  17.6 (+/- 5.3)  13.9 (+/- 3.8)  19.4 (+/- 8.1)   29.1  (+/- 6.3)

Daily users &&
 Cigarettes     10,343    NA @@   NA      74.9 (+/- 1.9)  79.6 (+/- 1.8)  17.5 (+/- 1.5)  85.0 (+/- 1.4)  37.4 (+/- 2.1)   90.9  (+/- 1.1)
 Alcohol         3,335    NA      NA      48.8 (+/- 3.8)  61.7 (+/- 5.3)  23.9 (+/- 3.2)  32.8 (+/- 2.9)  25.4 (+/- 4.0)   48.1  (+/- 3.7)
 Marijuana         830    NA      NA      51.9 (+/- 6.1)  49.9 (+/- 7.1)  30.7 (+/- 5.3)  39.0 (+/- 5.8)  17.8 (+/- 5.4)   59.8  (+/- 6.3)
 Cocaine           107    NA      NA      72.1 (+/-15.6)  66.0 (+/-21.4)  65.0 (+/-17.7)  62.7 (+/-17.9)  48.9 (+/-20.8)   78.9  (+/-14.9)
----------------------------------------------------------------------------------------------------------------------------------------------
*  Aged >=12 years.
+  Used cigarettes, alcohol, marijuana, or cocaine one or more times during the 30 days preceding the survey.
&  Tried to cut down on the use of substance; "felt unable to cut down on {their} use even though {they} tried"; "needed larger amounts to
   get the same effect"; "felt {they} needed or were dependent on {the substance}"; "had withdrawal symptoms, that is, felt sick because
   {they} stopped or cut down on {their} use."
@  Current substance users who responded yes to at least one of the last four indicators.
** 95% Confidence interval.
++ n=61,426.
&& Respondents who reported daily use for >=2 consecutive weeks during the 12 months preceding the survey; n=14,615.
@@ Not applicable.
==============================================================================================================================================

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