Narrowing the Gap: The Burden of Alcohol, Drugs, and Firearms on U.S. Life Expectancy

The gap in life expectancy between the United States and its peer nations has grown over the last two decades. The most recent life expectancy at birth (2022) in the United States (77.6 years) was among the lowest life expectancies found among all Organization for Economic Cooperation and Development (OECD) countries (the average was 80.6 years).1 Many authors have focused on the United States’ disproportionately high spending on health care, suggesting that life expectancy should be higher in this country as a result;2 3 4 however, both clinical and nonclinical factors, including certain public health investments and social and economic factors, are strongly correlated with decreases in longevity.5 6 7

While the life expectancy in the United States is an outlier among high-income countries, it is also an outlier in other ways that affect longevity. This snapshot examines the impact on life expectancy from three common, preventable causes of death in the United States: alcohol, drugs, and firearms.

In 2022, there were more than 48,000 firearm-related deaths (more than half were recorded as suicides, according to a forthcoming analysis by the AAMC Research and Action Institute); nearly 108,000 drug-related deaths; and more than 51,000 alcohol-induced deaths.8 While these numbers made up a small fraction of the nearly 3.3 million deaths in 2022 in the United States, they disproportionately affected children and younger adults — and, as a result, lowered the U.S. life expectancy at birth. If these deaths were eliminated (and other causes of death remained the same), life expectancy at birth would increase by 1.6 years.8 This analysis shows how shortened life expectancy is closely related to causes of death that can be lessened through targeted public health interventions and investments in mental health and social services, rather than making direct changes to clinical care. Mental health (including care for substance use disorders) and social services have often been excluded from what health insurers deem medically necessary,9 and thus have evolved separately from the core clinical care system in the United States. Life expectancy is heavily influenced by these traditionally nonclinical services, making it a potentially less useful measurement of clinical health care delivery outcomes in this country.10

In recent years, lower life expectancy in the United States has been commonly linked to COVID-19, unintentional injuries, heart disease, drug overdoses, and suicides.11 12 13 Life expectancy also correlates strongly with demographics, locations, and social and economic factors.14 15 People in southern states generally experience lower life expectancies than those in other regions of the country, with nine of the lowest state life expectancies in 2020 being in the southeast region.16 People with lower incomes also tend to have lower life expectancies than those with higher incomes, a trend that has been consistent over the years.17 Other factors, including access to education, lifestyle, environment, and genetic predisposition to disease, also play roles in measuring life expectancy in the United States.16 18

Compared to many OECD countries, the United States’ death rates for alcohol, drugs, and firearms have far exceeded other nations, and it consistently has had the highest rate of firearm-related deaths in children and teenagers, over 9.5 times the rate of Canada in 2021.19 Likewise, the United States has had the highest rate of drug-related deaths from commonly misused substances, with over 15 times the rate of Spain in 2021 (Figure 1).20 Prior to 2020, unintentional injuries (e.g., motor vehicle accidents) were the leading causes of death for young people ages 1-19; since 2020, firearms have been the leading cause of death for people ages 1-19. In 2022, drug use (including opioids) was the leading cause of death for Americans 1-44 years of age; firearms were the third-leading cause of death. The majority of firearm-related deaths in the United States are due to suicide,21 and 54.6% of total suicides in 2022 were by firearms.22 Children and adolescents (ages 1-19) in the United States saw the largest increases, specifically, in firearm-related and drug-related deaths from 2019 to 2022, when firearm-related deaths surpassed deaths from motor vehicle accidents and reached nearly 6 deaths per 100,000 people.8

^{Source: World Health Organization, the Global Health Observatory. Global health estimates: leading causes of death. Accessed September 12, 2024. https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death; Institute for Health Metrics and Evaluation, Global Health Data Exchange. Global Burden of Death Study 2021 results. Accessed September 12, 2024. https://vizhub.healthdata.org/gbd-results/}

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Opportunities to Add Potential Years of Life

In 2022, drug-related deaths accounted for the greatest loss of potential years of life expectancy at birth. In other words, if drug-related deaths did not occur, the average American could expect to live nearly one year longer (0.9 years). The United States would add an average of 0.4 years and 0.3 years of life expectancy if firearm-related and alcohol-induced deaths, respectively, were eliminated (Figure 2). Younger Americans would see the greatest opportunity for gaining potential years of life if these causes of death were eliminated, though each age group would be impacted to some degree if deaths due to alcohol, drugs, or firearms were eliminated or reduced.

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In addition, certain states would see a greater impact from eliminating these causes of death than others. For example, in West Virginia, Delaware, and Washington, D.C., the greatest increase in life expectancy (1.4 years) could be gained solely by eliminating deaths due to drugs. In New Mexico, Alaska, and South Dakota, focusing on alcohol would yield the greatest increase in life expectancy. In Louisiana, Mississippi, and New Mexico, residents would see the largest gains in life expectancy by eliminating deaths due to firearms. Overall, the potential years of life gained from eliminating all three of these causes of death are the largest in New Mexico, West Virginia, Alaska, Louisiana, and Washington, D.C. Overall, 10 states and the District of Columbia would see a jump of at least two years in life expectancy if deaths due to alcohol, drugs, and firearms did not occur, ranging from 2.0 years in South Carolina to 3.0 years in New Mexico.

Certain racial and ethnic groups in each state would also see dramatic increases in life expectancy if these deaths did not occur. Across the country, American Indian, Alaska Native, Black, White, and Hispanic populations would see the largest increases in life expectancy if alcohol-induced and drug- and firearm-related deaths were eliminated; Asian populations would only see minimal increases, and Native Hawaiian and other Pacific Islander populations would not see any impact on life expectancy. While the differences in potential years of life gained occur by race and ethnicity, this analysis does not examine how the many social and economic factors impact life expectancy across these groups.23

Collective Policy Can Close the Gap

Achieving zero deaths due to alcohol, drugs, and firearms is highly unlikely in the United States or elsewhere in the world. Nonetheless, federal and state policies can help decrease these deaths and improve life expectancy for all. Reducing causes of death that disproportionately impact children and young people is particularly important, since youth death rates have the greatest impact on the nation’s average life expectancy. Even a slight reduction in deaths due to the three causes listed above would bring the United States’ life expectancy at birth closer to the OECD average (Figure 3).

^{Source: CDC, National Center for Health Statistics. CDC Wonder. Underlying cause of death, 2018-2022, single race request. Accessed September 16, 2024. http://wonder.cdc.gov/ucd-icd10-expanded.html; OECD. Life expectancy at birth. In: Health at a Glance 2023: OECD Indicators. OECD Publishing; 2023. doi:10.1787/d90b402d-en}

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Findings from this analysis highlight that the United States’ lower life expectancy is impacted by three causes of death that are amenable to policy interventions at the national and state levels. If researchers and policymakers believe that life expectancy is a primary measure of a nation’s health, immediate gains are likely to be achieved through targeted efforts affecting these three major causes of death.

The United States has successfully reduced car crash deaths, beginning in the 1970s, by instituting seatbelt laws, drunk driving awareness campaigns, changes in the engineering of cars, and other interventions.24 25 Similar interventions have been proven to be effective for helping to reduce alcohol and substance use, firearm injury, and suicide rates, ranging from access to treatment for mental health and substance use disorders, to policy measures (like firearm safe storage laws26 27 and limitations on hours of alcohol sale 28 ), to enhancement of community mentoring programs29 30 and installment of gardens and green space.31 32 33 Collectively, these interventions and others have potentially large effects on all firearm- and drug-related and alcohol-induced causes of death that contribute to decreased life expectancy. U.S. policymakers and community members with the goal of improving life expectancy at birth should consider federal, state, and international examples of investments to help minimize these and other preventable causes of death across the country.

Methods

The numbers of deaths and population sizes were sourced from the CDC WONDER online database, “About Underlying Cause of Death, 2018-2022, Single Race.” Data are from the Multiple Cause of Death files (2018-2022), as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program, maintained by the National Center for Health Statistics.34 Table 1 lists the ICD-10 codes utilized to determine deaths due to drugs, firearms, and alcohol.   

^{Source: KFF. State health facts. Accessed September 13, 2024. https://www.kff.org/statedata/}

These data were then used to calculate life expectancies using the County Health Rankings & Roadmaps mortality calculator.35 R statistical software was used to automate the formulas to calculate life expectancy across all race or ethnicity and age groups for each cause of death. In the analyses, all races are of non-Hispanic origin, while those marked as Hispanic may be of any race.