The deadlier drug crises that we don’t consider public health emergencies

In 2016, this drug was linked to more deaths than guns, car crashes, or even HIV/AIDS at its peak. Actually, it was associated with more deaths than guns and car crashes combined.

I’m not talking about opioids. I’m talking about alcohol.

According to the Centers for Disease Control and Prevention (CDC), alcohol is linked to 88,000 deaths each year — more than all the 64,000 drug overdose deaths in 2016. That includes all potential alcohol deaths: liver cirrhosis, poisonings, crimes related to alcohol, driving while intoxicated, and so on. But it’s a very high death rate — making alcohol the third leading cause of preventable death in the US.

What’s worse, the 88,000 number may, at this point, be an underestimate. The figure comes from an analysis of deaths between 2006 and 2010. But since then, we’ve seen some signs that alcohol deaths may have gone up: Between 2010 and 2015, the number of alcohol-induced deaths (those that involve direct health complications from alcohol, like liver cirrhosis) rose from nearly 26,000 to more than 33,000.

Alcohol isn’t even the deadliest drug in the US; that would be tobacco. Smoking is linked to, depending on the estimate, 480,000 to 540,000 deaths each year — the leading preventable cause of death in America. (This figure is potentially too high, since it’s based on mortality data from 2005 to 2009, and smoking rates have dropped since then. Still, it’s an extremely high death toll.)

Yet all of these deaths didn’t inspire President Donald Trump or the presidents before him to formally declare a public health emergency over tobacco or alcohol, as Trump finally did for opioids on Thursday. We don’t often call alcohol or tobacco “epidemics,” even as we regularly use that same language for opioids that are linked to a fraction of the deaths from alcohol or tobacco.

Maybe we should. We have a lot of evidence that we could do much more to combat alcohol and tobacco deaths. But we haven’t.

We’ve become desensitized to legal drug deaths

Part of the reason there are far more deaths from alcohol and tobacco than other drugs is because alcohol and tobacco are legal for recreational purposes and, therefore, far more accessible. If you were to look at deaths per user, several other drugs — such as the dangerous synthetic opioid fentanyl — would very likely pull ahead.

But that’s not a reason to ignore the problems alcohol and tobacco pose. They still lead to tens of thousands of people needlessly dying in the case of alcohol and hundreds of thousands dying when it comes to tobacco.

Yet we have become desensitized to these drugs. When I’ve asked drug policy experts about this, they have attributed it to the fact that alcohol and tobacco — and the deaths they cause — have just been with us for a long time. That’s made the deaths feel routine.

That’s not to say that policymakers have done nothing about either. Anti-tobacco campaigns, particularly since the 1990s, have done a lot to reduce smoking rates. (About 16.8 percent of adults reported smoking recently in 2014, down from 42.4 percent in 1965.) Similarly, the push to take drunk driving seriously in the 1980s helped reduce both alcohol-related deaths and car crashes.

But we don’t seem to take these issues very seriously. Even after the efforts of the past few decades, tobacco use is linked to hundreds of thousands deaths a year and alcohol use is linked to tens of thousands of deaths a year. Yet how often do you see the president or other federal lawmakers making big speeches about either, calling for a national emergency declaration?

Lawmakers don’t even take these issues seriously when the money to do something about them is simply handed over. In the 1990s, states sued tobacco companies for all the death and disease their products have caused, reaching the Master Settlement Agreement. The idea was that tobacco companies would over time pay an exorbitant amount of money — more than $240 billion over 25 years — that could then be used for anti-tobacco programs.

Yet when NPR checked in on the settlement in 2013, it found that the money had not been used as planned: “Colorado has spent tens of millions of its share to support a literacy program, while Kentucky has invested half of its money in agricultural programs.” In the end, states fell far short of the goal, recommended by the CDC, to spend 14 percent of their settlement funds on anti-smoking programs.

And this is tobacco, which is widely recognized as a public health menace. Similar efforts to treat alcohol as a serious public health issue don’t even exist.

That’s not because we are helpless in the face of alcohol and tobacco; to the contrary, there are plenty of evidence-backed policy proposals out there. It’s because we are, as a country, seemingly apathetic to the death these drugs cause.

There are plenty of things we could do about alcohol and tobacco

In drug policy discussions, we typically talk about drugs in a binary framework: You either legalize them or prohibit them. Whenever I write about alcohol-related deaths, for example, I get a ton of reader emails asking why I want Prohibition to come back. Don’t I know how much of a failure that was?

The reality, though, is there are plenty of policy interventions we could take on before reaching for prohibition.

For alcohol, the research backs raising the alcohol tax. It supports limiting the number of alcohol outlets. There are innovative evidence-based policies that temporarily yank a person’s right to drink if they get in trouble with the law due to alcohol. We could also put states, instead of private businesses, in charge of alcohol sales, which the research shows can keep prices higher, reduce access to youth, and reduce overall levels of use. And we could increase access to evidence-based addiction treatment.

With tobacco, we have other evidence-backed policies: raising taxes to reduce access; improving access to safer alternatives to smoking like nicotine gum, nicotine patches, and e-cigarettes; using stronger warning labels; and raising the smoking age.

Some jurisdictions have taken up these kinds of interventions. New York City, for one, has a famously high cigarette tax, and it has a phone line that people can use to get in touch with a clinic or obtain free nicotine patches or free nicotine gum; it has seen its smoking rate drop from 21.5 percent in 2002 to 14.3 percent in 2015. Meanwhile, five states have increased their legal smoking age to 21.

These policy interventions, though, aren’t pushed with the same kind of vigor and all-hands-on-deck effort we see with opioids, at least rhetorically, today. That’s especially the case with alcohol, which is many Americans’ drug of choice and has a powerful, big lobby behind it — making lawmakers cautious about raising alcohol taxes even to keep up with inflation or instituting policies as simple as labeling alcohol with nutrition facts.

We saw this as Trump gave his speech about his opioid emergency. He acknowledged that alcohol can be a big problem, retelling the tragic story of his own brother’s battle with alcohol addiction and eventual death as a result.

“He was a strong guy, but it was a tough, tough thing that he was going through,” Trump said. “But I learned because of Fred. I learned.”

At the end of the day, though, Trump’s emergency declaration wasn’t about alcohol. It was only about a group of drugs that, while absolutely dangerous and in need of more policy interventions, is linked to fewer deaths than everyday booze.