Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

Acknowledgments

Tis report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA),

U.S. Department of Health and Human Services (HHS), under Contract No. HHSS283201700002C with

RTI International. Douglas Richesson and Jennifer M. Hoenig were the SAMHSA authors. Rong Cai served as the

government project officer and as the contracting officer representative.

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Recommended Citation

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators

in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No.

PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality,

Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

Originating Office

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5600 Fishers Lane, Room 15-E09D, Rockville, MD 20857. For questions about this report, please e-mail

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SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, or sex. SAMHSA cumple con las leyes federales de derechos civiles aplicables y no

discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Behavioral Health Statistics and Quality

Populations Survey Branch

Publication Number PEP21-07-01-003

October 2021

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

| iii

Table of Contents

Summary

Nonprescription Cough and Cold Medicine Misuse

Kratom Use

Introduction

Synthetic Marijuana Use

Survey Background

Synthetic Stimulant Use

Data Collection in the First Quarter of 2020

Initiation of Substance Use

Changes to Data Collection Methods Because of the

Initiation of Cigarette Use

COVID-19 Pandemic

Initiation of Alcohol Use

Data Presentation and Interpretation

Initiation of Marijuana Use

Presentation of National Estimates for 2020

Initiation of Cocaine Use

Interpretation of Estimates for 2020

Initiation of Heroin Use

Initiation of Methamphetamine Use

General Substance Use in the Past Month

Initiation of Hallucinogen Use

Tobacco Use or Nicotine Vaping in the Past Month

Initiation of Inhalant Use

Tobacco Product Use

Initiation of Prescription Stimulant Misuse

Cigarette Use

Initiation of Prescription Tranquilizer or Sedative Misuse

Daily Cigarette Use

Initiation of Prescription Tranquilizer Misuse

Nicotine Vaping

Initiation of Prescription Sedative Misuse

Underage Tobacco Use or Nicotine Vaping

Initiation of Prescription Pain Reliever Misuse

Alcohol Use in the Past Month

Perceived Risk from Substance Use

Any Alcohol Use

Substance Use Disorders in the Past Year

Binge Alcohol Use

Alcohol Use Disorder

Heavy Alcohol Use

Illicit Drug Use Disorder

Underage Alcohol Use

Marijuana Use Disorder

Illicit Drug Use in the Past Year

Cocaine Use Disorder

Any Illicit Drug Use

Heroin Use Disorder

Marijuana Use

Methamphetamine Use Disorder

Cocaine Use

Prescription Stimulant Use Disorder

Heroin Use

Prescription Tranquilizer Use Disorder or Sedative Use Disorder

Methamphetamine Use

Prescription Pain Reliever Use Disorder

Hallucinogen Use

Opioid Use Disorder

Inhalant Use

Central Nervous System Stimulant Use Disorder

Misuse of Psychotherapeutic Drugs

Major Depressive Episode in the Past Year

Stimulant Misuse

MDE and MDE with Severe Impairment among Adolescents

Tranquilizer or Sedative Misuse

MDE and MDE with Severe Impairment among Adults

Benzodiazepine Misuse

Pain Reliever Misuse

Any Mental Illness among Adults in the Past Year

Misuse of Subtypes of Pain Relievers

Serious Mental Illness among Adults in the Past Year

Main Reasons for the Last Misuse of Pain Relievers

Source of the Last Pain Reliever That Was Misused

Co-Occurring MDE and SUD among Adolescents

Opioid Misuse

Substance Use among Adolescents with MDE

Central Nervous System Stimulant Misuse

Co-Occurring Mental Health Issues and SUD among Adults

Other Substance Use in the Past Year

Co-Occurring AMI and SUD

GHB Use

Co-Occurring SMI and SUD

Key Substance Use and Mental Health Indicators in the United States:

| October 2021

Results from the 2020 National Survey on Drug Use and Health

Substance Use among Adults, by Mental Illness Status

Receipt of Virtual (Telehealth) Mental Health Services

among Adults with SMI

Suicidal Thoughts and Behaviors among Adults

Perceived Unmet Need for Mental Health Services

Serious Thoughts of Suicide among Adults

among Adults with Mental Illness

Suicide Plans among Adults

Perceived Unmet Need for Mental Health Services

Suicide Attempts among Adults

among Adults with AMI

Suicidal Thoughts and Behaviors among Adults Because

Perceived Unmet Need for Mental Health Services

of COVID-19

among Adults with SMI

Reasons for Not Receiving Mental Health Services

Suicidal Thoughts and Behaviors among Adolescents

among Adults with Mental Illness and a Perceived

Substance Use Treatment in the Past Year

Unmet Need

Need for Substance Use Treatment

Receipt of Services for Co-Occurring Substance Use

Receipt of Substance Use Treatment

Disorder and Mental Health Issues

Receipt of Any Substance Use Treatment

Receipt of Services among Adolescents with

Receipt of Any Substance Use Treatment among

Co-Occurring SUD and an MDE

People with a Past Year SUD

Receipt of Services among Adults with Co-Occurring SUD and AMI

Receipt of Substance Use Treatment at a Specialty Facility

Receipt of Services among Adults with Co-Occurring SUD and SMI

Receipt of Substance Use Treatment at a Specialty

Facility among People Who Needed Substance

Perceived Recovery

Use Treatment

Substance Use, Mental Health Issues, and the COVID-19

Receipt of Virtual (Telehealth) Services for Substance

Pandemic

Use Treatment

Perceived Negative Effects on Mental Health Because of

Perceived Need for Substance Use Treatment

the COVID-19 Pandemic

Reasons for Not Receiving Substance Use Treatment

Perceived Negative Effects on Mental Health Because

Medication-Assisted Treatment for Alcohol Use or Opioid Misuse

of the COVID-19 Pandemic among Adolescents

Medication-Assisted Treatment for Alcohol Use

Aged 12 to 17

Medication-Assisted Treatment for Opioid Misuse

Perceived Negative Effects on Mental Health Because

Mental Health Service Use in the Past Year

of the COVID-19 Pandemic among Adults Aged 18 or Older

Treatment for Depression among Adolescents

Perceived Effects on Substance Use Because of the

Treatment for Depression among Adults

COVID-19 Pandemic

Mental Health Service Use among Adolescents

Perceived Effects on Alcohol Use

Receipt of Mental Health Services in Specialty and

Perceived Effects on the Use of Drugs Other than Alcohol

Nonspecialty Settings among Adolescents

Perceived Effects on Access to Services Because of the

Receipt of Virtual (Telehealth) Mental Health Services

COVID-19 Pandemic

among Adolescents

Access to Substance Use Treatment

Mental Health Service Use among Adults

Access to Mental Health Services

Receipt of Inpatient or Outpatient Mental Health

Access to Medical Services

Services or Prescription Medication among Adults

Endnotes

Receipt of Virtual (Telehealth) Mental Health Services

among Adults

Appendix A: Special Tables of Estimates for Substance

Mental Health Service Use among Adults with AMI

Use and Mental Health Indicators in the United States

A-1

Receipt of Inpatient or Outpatient Mental Health

Services or Prescription Medication among Adults with AMI

Receipt of Virtual (Telehealth) Mental Health Services

among Adults with AMI

Mental Health Service Use among Adults with SMI

Receipt of Inpatient or Outpatient Mental Health

Services or Prescription Medication among Adults with SMI

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

Summary

•

Among people aged 12 or older in 2020 who used any

tobacco product in the past month (regardless of whether

Te National Survey on Drug Use and Health (NSDUH)

they vaped nicotine), 65.3 percent smoked cigarettes but

underwent some major methodological changes for 2020,

did not use other tobacco products, 14.8 percent smoked

including a shift to web-based interviewing in Quarter 4 (i.e.,

cigarettes and used some other type of tobacco product,

October to December). In addition, 2020 marked the first

and 19.9 percent used only noncigarette tobacco products

year in which substance use disorders (SUDs) were evaluated

(i.e., other tobacco products but not cigarettes).

using criteria defined in the Diagnostic and Statistical Manual

of Mental Disorders, 5th edition (DSM-5), as opposed to

•

In 2020, 10.4 million people aged 12 or older (or

criteria specified in the Diagnostic and Statistical Manual of

3.8 percent) used an e-cigarette or other vaping device to

Mental Disorders, 4th edition (DSM-IV). Additional changes

vape nicotine in the past month. Te percentage of people

were made to the questionnaire itself. Terefore, care must be

who vaped nicotine was highest among young adults aged

taken when attempting to disentangle the effects on estimates

18 to 25 (11.7 percent or 3.9 million people), followed

due to real changes in the population (e.g., the coronavirus

by adolescents aged 12 to 17 (5.1 percent or 1.3 million

disease 2019 [COVID-19] pandemic and other events) from

people), then by adults aged 26 or older (2.4 percent or

the effects of these methodological changes.

5.2 million people).

•

Among people aged 12 to 20 in 2020, 11.8 percent (or

Substance Use

4.4 million people) used tobacco products or used an

• Among people aged 12 or older in 2020, 58.7 percent (or

e-cigarette or other vaping device to vape nicotine in the

162.5 million people) used tobacco, alcohol, or an illicit

past month. Among people in this age group, 7.7 percent

drug in the past month (also defined as “current use”),

(or 2.9 million people) vaped nicotine, 6.7 percent

including 50.0 percent (or 138.5 million people) who

(or 2.5 million people) used tobacco products, and

drank alcohol, 18.7 percent (or 51.7 million people) who

4.1 percent (or 1.5 million people) smoked cigarettes in

used a tobacco product, and 13.5 percent (or 37.3 million

the past month.

people) who used an illicit drug.

Alcohol Use

Tobacco Product Use or Nicotine Vaping

• Among people aged 12 or older in 2020, 22.2 percent

• Among people aged 12 or older in 2020, 20.7 percent (or

(or 61.6 million people) were binge alcohol users in the

57.3 million people) used tobacco products or used an

past month. Te percentage was highest among young

e-cigarette or other vaping device to vape nicotine in the

adults aged 18 to 25 (31.4 percent or 10.5 million

past month.

people), followed by adults aged 26 or older (22.9 percent

or 50.0 million people), then by adolescents aged 12 to 17

• Among people in 2020 who used tobacco products or

(4.1 percent or 1.0 million people).

vaped nicotine in the past month (i.e., nicotine product

users), the use of specific nicotine products varied by age

• Among the 138.5 million current alcohol users aged 12 or

group. Nearly two thirds of adolescents aged 12 to 17 who

older in 2020, 61.6 million people (or 44.4 percent) were

used nicotine products in the past month (63.1 percent)

past month binge drinkers. Among past month binge

vaped nicotine but did not use tobacco products. Among

drinkers, 17.7 million people (28.8 percent of current

adults aged 26 or older who used nicotine products in

binge drinkers and 12.8 percent of current alcohol users)

the past month, however, 88.9 percent used only tobacco

were past month heavy drinkers.

products.

• Among people aged 12 to 20 in 2020, 16.1 percent

(or 6.0 million people) were past month alcohol users.

Estimates of binge alcohol use and heavy alcohol

use in the past month among underage people were

9.2 percent (or 3.4 million people) and 1.8 percent (or

669,000 people), respectively.

Key Substance Use and Mental Health Indicators in the United States:

2 | October 2021

Results from the 2020 National Survey on Drug Use and Health

Illicit Drug Use

Initiation of Substance Use

•

Among people aged 12 or older in 2020, 21.4 percent (or

•

Among people aged 12 or older in 2020, 1.3 million

59.3 million people) used illicit drugs in the past year.

people initiated cigarette smoking in the past year (i.e.,

never smoked cigarettes before the past 12 months). Te

•

In 2020, marijuana was the most commonly used illicit

vast majority of people (approximately 90 percent of past

drug, with 17.9 percent of people aged 12 or older

year initiates) tried cigarettes for the first time by age 25.

(or 49.6 million people) using it in the past year. Te

Corresponding numbers of initiates of cigarette smoking

percentage was highest among young adults aged 18 to

by age group were 385,000 adolescents aged 12 to 17,

25 (34.5 percent or 11.6 million people), followed by

752,000 young adults aged 18 to 25, and 127,000 adults

adults aged 26 or older (16.3 percent or 35.5 million

aged 26 or older.

people), then by adolescents aged 12 to 17 (10.1 percent

or 2.5 million people).

•

Among people aged 12 or older in 2020, 4.1 million

people initiated alcohol use in the past year, not counting

•

Among people aged 12 or older in 2020, 3.7 percent

sips from another person’s drink. Consistent with the

(or 10.3 million people) misused central nervous

pattern for initiation of cigarette smoking, relatively few

system (CNS) stimulants in the past year. Among the

people started to use alcohol after age 25. Corresponding

10.3 million people who misused CNS stimulants in the

numbers for initiation of alcohol use by age group were

past year, about one third used only cocaine (32.4 percent

1.8 million adolescents aged 12 to 17, 2.1 million young

of CNS stimulant misusers or 3.3 million people),

adults aged 18 to 25, and 176,000 adults aged 26 or

about one third misused only prescription stimulants

older.

(32.3 percent of CNS stimulant misusers or 3.3 million

people), and about 1 in 7 used only methamphetamine

•

Among people aged 12 or older in 2020, 2.8 million

(14.4 percent of CNS stimulant misusers or 1.5 million

people initiated marijuana use in the past year, including

people). An estimated 353,000 people used or misused

1.0 million adolescents aged 12 to 17, 1.1 million young

all three CNS stimulants in the past year (3.4 percent of

adults aged 18 to 25, and 664,000 adults aged 26 or

CNS stimulant misusers).

older. Consistent with the pattern for cigarette smoking

and alcohol use, most people started using marijuana

•

Among people aged 12 or older in 2020, 3.4 percent

before age 26.

(or 9.5 million people) misused opioids (heroin or

prescription pain relievers) in the past year. Among the

•

Among people aged 12 or older in 2020, 1.2 million

9.5 million people who misused opioids in the past year,

people initiated prescription pain reliever misuse in

9.3 million people misused prescription pain relievers

the past year. Unlike initiates of cigarette, alcohol, and

compared with 902,000 people who used heroin.

marijuana use, nearly two thirds of past year initiates

tried prescription pain relievers for the first time after age

•

Among people aged 12 or older in 2020, 3.3 percent (or

25 (i.e., 774,000 adults aged 26 or older who initiated

9.3 million people) misused prescription pain relievers in

prescription pain reliever misuse).

the past year. Te percentage was highest among young

adults aged 18 to 25 (4.1 percent or 1.4 million people),

Perceived Risk from Substance Use

followed by adults aged 26 or older (3.4 percent or

• Among people aged 12 or older in 2020, 70.7 percent of

7.5 million people), then by adolescents aged 12 to 17

people perceived great risk of harm from smoking one or

(1.6 percent or 396,000 people).

more packs of cigarettes a day, and 68.7 percent perceived

•

In 2020, 2.6 percent of people aged 12 or older (or

great risk from having four or five alcoholic drinks nearly

7.1 million people) used hallucinogens in the past year.

every day. Percentages of people who perceived great risk

Te percentage among young adults aged 18 to 25

from cocaine or heroin use once or twice a week were

(7.3 percent or 2.4 million people) was higher than the

84.7 and 93.2 percent, respectively. In contrast, about one

percentages among adolescents aged 12 to 17 (1.5 percent

fourth of people (27.4 percent) perceived great risk from

or 370,000 people) or adults aged 26 or older (2.0 percent

smoking marijuana once or twice a week.

or 4.3 million people).

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

• Adults aged 26 or older were more likely than adolescents

• Among adults aged 18 or older in 2020, 8.4 percent

aged 12 to 17 or young adults aged 18 to 25 to perceive

(or 21.0 million people) had a past year MDE, and

great risk of harm from smoking one or more packs of

6.0 percent (or 14.8 million people) had a past year MDE

cigarettes per day or to perceive great risk of harm from

with severe impairment. Percentages for past year MDE

daily binge drinking.

and MDE with severe impairment were highest among

young adults aged 18 to 25, followed by adults aged 26 to

• Young adults aged 18 to 25 in 2020 were less likely than

49, then by adults aged 50 or older. Among young adults,

adolescents aged 12 to 17 or adults aged 26 or older

17.0 percent (or 5.6 million people) had a past year

to perceive great risk of harm from smoking marijuana

MDE, and 12.1 percent (or 4.0 million people) had a

weekly.

past year MDE with severe impairment.

Substance Use Disorders in the Past Year

Mental Illness among Adults

•

As stated previously, the 2020 survey marked the first year

• Among adults aged 18 or older in 2020, 21.0 percent (or

in which SUDs were assessed using the criteria defined

52.9 million people) had any mental illness (AMI) and

in DSM-5 instead of criteria specified in DSM-IV. Tis

5.6 percent (or 14.2 million people) had serious mental

change from DSM-IV to DSM-5 criteria for assessing

illness (SMI) in the past year.

SUDs led to breaks in the comparability of 2020 SUD

estimates with estimates from prior years.

• Percentages of adults in 2020 with AMI or SMI in the

past year were highest among young adults aged 18 to

•

In 2020, 40.3 million people aged 12 or older (or

25, followed by adults aged 26 to 49, then by adults

14.5 percent) had an SUD in the past year, including

aged 50 or older. Among young adults, 30.6 percent

28.3 million who had alcohol use disorder, 18.4 million

(or 10.2 million people) had AMI, and 9.7 percent (or

who had an illicit drug use disorder, and 6.5 million

3.3 million people) had SMI in the past year.

people who had both alcohol use disorder and an illicit

drug use disorder.

Co-Occurring Mental Health Issues and Substance Use

•

In 2020, the percentage of people aged 12 or older with

Disorder

an alcohol use disorder was highest among young adults

• Among adolescents aged 12 to 17 in 2020, 20.9 percent

aged 18 to 25 (15.6 percent or 5.2 million people),

(or 5.1 million people) had either an SUD or an MDE in

followed by adults aged 26 or older (10.3 percent or

the past year, 14.4 percent (or 3.5 million people) had an

22.4 million people), then by adolescents aged 12 to 17

MDE but not an SUD, 3.7 percent (or 900,000 people)

(2.8 percent or 712,000 people). Young adults also were

had an SUD but not an MDE, and 2.7 percent (or

more likely than adolescents or adults aged 26 or older to

644,000 people) had both an MDE and an SUD in the

have had at least one illicit drug use disorder in the past

past year.

year.

• Among adults aged 18 or older in 2020, 29.3 percent (or

Major Depressive Episode

73.8 million people) had either AMI or an SUD in the

past year, 14.2 percent (or 35.9 million people) had AMI

• Among adolescents aged 12 to 17 in 2020, 17.0 percent

but not an SUD, 8.3 percent (or 20.9 million people) had

(or 4.1 million people) had a past year major depressive

an SUD but not AMI, and 6.7 percent (or 17.0 million

episode (MDE), and 12.0 percent (or 2.9 million people)

people) had both AMI and an SUD.

had a past year MDE with severe impairment.

• Among adults aged 18 or older in 2020, 18.4 percent (or

46.5 million people) had either SMI or an SUD in the

past year, 3.4 percent (or 8.5 million people) had SMI but

not an SUD, 12.8 percent (or 32.3 million people) had

an SUD but not SMI, and 2.2 percent (or 5.7 million

people) had both SMI and an SUD.

Key Substance Use and Mental Health Indicators in the United States:

4 | October 2021

Results from the 2020 National Survey on Drug Use and Health

Substance Use among People with Mental Health

Substance Use Treatment

Issues

• People were classified as needing substance use treatment

•

Among adolescents aged 12 to 17 in 2020, those with a

if they had an SUD in the past year or if they received

past year MDE were more likely than adolescents without

substance use treatment at a specialty facility in the

a past year MDE to be past year illicit drug users (28.6 vs.

past year. Among people aged 12 or older in 2020,

10.7 percent) or past year marijuana users (22.0 vs.

14.9 percent (or 41.1 million people) needed substance

7.9 percent). Adolescents with a past year MDE also were

use treatment in the past year.

more likely than those without a past year MDE to be

• Among people aged 12 or older in 2020, 1.4 percent (or

past month binge alcohol users (6.2 vs. 3.8 percent). In

4.0 million people) received any substance use treatment

addition, adolescents with a past year MDE were more

in the past year, and 1.0 percent (or 2.7 million people)

likely than those without a past year MDE to use tobacco

received substance use treatment at a specialty facility in

products or vape nicotine in the past month (12.9 vs.

the past year.

5.1 percent).

• Among the 38.4 million people aged 12 or older

•

Among adults aged 18 or older in 2020, those with SMI

in 2020 with an SUD in the past year who did not

or AMI in the past year were more likely than those

receive treatment at a specialty facility, 97.5 percent

with no mental illness in the past year to be past year

(or 37.5 million people) did not feel that they needed

users of illicit drugs (47.8 percent for adults with SMI

treatment, 1.9 percent (or 737,000 people) felt that

and 39.8 percent for adults with AMI vs. 17.0 percent

they needed treatment but did not make an effort to

for adults with no mental illness), past year users of

get treatment, and 0.5 percent (or 211,000 people) felt

marijuana (39.2 and 32.8 percent vs. 14.6 percent), or

that they needed treatment and made an effort to get

past year misusers of opioids (i.e., heroin users or misusers

treatment.

of prescription pain relievers) (11.6 and 8.1 percent vs.

2.3 percent).

Treatment for Depression

•

Adults aged 18 or older in 2020 with SMI or AMI in the

• Among the 4.1 million adolescents aged 12 to 17 in 2020

past year were more likely than adults with no mental

who had a past year MDE, 41.6 percent (or 1.7 million

illness in the past year to be past month binge alcohol

people) received treatment for depression in the past year.

users (30.9 and 28.5 percent vs. 22.8 percent) and to

• Among the 21.0 million adults aged 18 or older in 2020

use tobacco products or vape nicotine in the past month

who had a past year MDE, 66.0 percent (or 13.8 million

(37.4 and 30.9 percent vs. 19.6 percent).

people) received treatment for depression in the past year.

Suicidal Thoughts and Behavior

Mental Health Services

• Among adults aged 18 or older in 2020, 4.9 percent (or

• In 2020, 17.3 percent of adolescents aged 12 to 17 (or

12.2 million people) had serious thoughts of suicide,

4.2 million people) received mental health services in a

1.3 percent (or 3.2 million people) made a suicide plan,

specialty setting, including 16.6 percent (or 4.1 million

and 0.5 percent (or 1.2 million people) attempted suicide

people) who received mental health treatment in an

in the past year.

outpatient setting and 2.1 percent (or 510,000 people)

• Among young adults aged 18 to 25 in 2020, 11.3 percent

who received mental health treatment in an inpatient

(or 3.8 million people) had serious thoughts of suicide,

setting.

4.0 percent (or 1.3 million people) made a suicide plan,

• In 2020, 16.9 percent of adults aged 18 or older (or

and 1.9 percent (or 627,000 people) attempted suicide in

41.4 million people) received inpatient or outpatient

the past year.

mental health services or took prescription medication

• Among adolescents aged 12 to 17 in 2020, 12.0 percent

in the past year for a mental health issue, including

(or 3.0 million people) had serious thoughts of suicide,

0.9 percent (or 2.2 million people) who received inpatient

5.3 percent (or 1.3 million people) made a suicide plan,

services, 8.8 percent (or 21.5 million people) who received

and 2.5 percent (or 629,000 people) attempted suicide in

outpatient services, and 13.8 percent (or 33.8 million

the past year.

people) who took prescription medication.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

• Among the 52.9 million adults aged 18 or older in 2020

• Among the 5.7 million adults aged 18 or older in 2020

with AMI in the past year, 46.2 percent (or 24.3 million

who had a co-occurring SUD and SMI in the past year,

people) received inpatient or outpatient mental health

66.4 percent (or 3.7 million people) received either

services or took prescription medication in the past

substance use treatment at a specialty facility or mental

year for a mental health issue. However, among the

health services in the past year, including 55.4 percent

14.2 million adults aged 18 or older in 2020 with SMI in

(or 3.1 million people) who received only mental health

the past year, 35.5 percent (or 5.0 million people) did not

services, 1.6 percent (or 89,000 people) who received

receive any of these services in the past year.

only substance use treatment at a specialty facility, and

9.3 percent (or 529,000 people) who received both

Perceived Unmet Need for Mental Health Services

substance use treatment at a specialty facility and mental

among Adults with Mental Illness

health services.

• Among the 52.9 million adults aged 18 or older in 2020

Substance Use, Mental Health Issues, and the

with AMI in the past year, 30.5 percent (or 16.1 million

COVID-19 Pandemic

people) perceived an unmet need for mental health

services in the past year.

•

In Quarter 4 of 2020, most adolescents aged 12 to 17

perceived at least some negative effect of the COVID-19

• Among the 14.2 million adults aged 18 or older in 2020

pandemic on their mental health, including about 1 in

with SMI in the past year, 49.7 percent (or 7.0 million

5 (18.3 percent or 4.5 million people) who perceived

people) perceived an unmet need for mental health

that the COVID-19 pandemic negatively affected their

services in the past year.

mental health “quite a bit or a lot.” Adolescents who

had a past year MDE or a past year MDE with severe

Receipt of Services for Co-Occurring Substance Use

impairment were more likely than those without a

Disorder and Mental Health Issues

past year MDE to perceive that the COVID-19 pandemic

• Among the 644,000 adolescents aged 12 to 17 in

negatively affected their mental health “quite a bit or a

2020 with a co-occurring SUD and an MDE in the

lot.”

past year, 69.0 percent (or 438,000 people) received

•

Similar to adolescents, most adults aged 18 or older in

either substance use treatment at a specialty facility or

Quarter 4 of 2020 perceived at least some negative effect

mental health services in the past year, 66.8 percent (or

of the COVID-19 pandemic on their mental health,

424,000 people) received only mental health services, and

including about 1 in 5 (18.3 percent or 45.2 million

0.9 percent (or 6,000 people) received both substance use

people) who perceived that the COVID-19 pandemic

treatment at a specialty facility and mental health services.

negatively affected their mental health “quite a bit or a

• Among the 17.0 million adults aged 18 or older in 2020

lot.” Adults with AMI or SMI in the past year were more

with a co-occurring SUD and AMI in the past year,

likely than those who did not have mental illness in the

50.5 percent (or 8.5 million people) received either

past year to perceive that the COVID-19 pandemic

substance use treatment at a specialty facility or mental

negatively affected their mental health “quite a bit or a

health services in the past year, including 42.3 percent

lot.”

(or 7.2 million people) who received only mental health

services, 2.5 percent (or 423,000 people) who received

only substance use treatment at a specialty facility, and

5.7 percent (or 960,000 people) who received both

substance use treatment at a specialty facility and mental

health services.

Key Substance Use and Mental Health Indicators in the United States:

6 | October 2021

Results from the 2020 National Survey on Drug Use and Health

•

Among people aged 12 or older in Quarter 4 of 2020

•

Among people aged 12 or older in Quarter 4 of 2020,

who drank alcohol in the past year, most perceived

nearly 1 in 3 (31.3 percent or 84.6 million people)

that they drank “about the same” amount as they did

had medical appointments moved from in person

before the COVID-19 pandemic began (59.4 percent or

to telehealth, and more than 1 in 4 (29.4 percent or

100.0 million people), but 15.4 percent (or 25.9 million

79.4 million people) experienced delays or cancellations

people) perceived that they drank “a little more or much

in medical appointments or preventive services. About

more.” Te percentage of young adult alcohol users aged

1 in 11 people (8.9 percent or 23.9 million people)

18 to 25 who perceived that they drank “a little more

experienced delays in getting prescriptions, and 1 in 20

or much more” than they did before the COVID-19

(5.6 percent or 15.1 million people) were unable to access

pandemic began (18.2 percent or 3.7 million people)

needed medical care resulting in a perceived moderate or

was higher than the corresponding percentage among

severe impact on health.

adults aged 26 or older who used alcohol in the past year

•

Among adults aged 18 or older in Quarter 4 of 2020

(15.0 percent or 21.8 million people).

who received mental health services in the past year,

•

Among people aged 12 or older in Quarter 4 of 2020 who

more than half (58.3 percent or 26.6 million people)

used drugs other than alcohol in the past year, more than

had appointments moved from in person to telehealth,

half (57.5 percent or 60.6 million people) perceived that

more than 1 in 3 (38.7 percent or 17.7 million people)

they used these drugs “about the same” as they did before

experienced delays or cancellations in appointments,

the COVID-19 pandemic began, but 10.3 percent (or

about 1 in 6 (16.0 percent or 7.3 million people)

10.9 million people) perceived that they used these drugs

experienced delays in getting prescriptions, and about

“a little more or much more.” Te percentage of past year

1 in 10 (10.7 percent or 4.9 million people) were unable

users of drugs other than alcohol who perceived that they

to access needed care resulting in a perceived moderate to

used these drugs “a little more or much more” than they

severe impact on health.

did before the COVID-19 pandemic was higher among

adolescents aged 12 to 17 (15.2 percent or 665,000

people) and young adults aged 18 to 25 (18.7 percent or

2.5 million people) than among adults aged 26 or older

(8.8 percent or 7.7 million people).

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

Introduction

in order to determine whether zero, one, or two household

residents aged 12 or older should be selected for the interview.

Substance use and mental health issues have significant

NSDUH collected in-person data using audio computer-

impacts on people, families, communities, and societies.1,2,3,4

assisted self-interviewing (ACASI), in which respondents read

Te National Survey on Drug Use and Health (NSDUH),

or listened to the questions on headphones and entered their

conducted annually by the Substance Abuse and Mental Health

answers directly into a NSDUH laptop computer. ACASI was

Services Administration (SAMHSA), provides nationally

designed for accurate reporting of information by providing

representative data on use of tobacco, alcohol, and illicit

respondents with a highly private and confidential mode for

drugs; substance use disorders (SUDs); receipt of substance

responding to questions about illicit drug use, mental health

use treatment; mental health issues; and use of mental health

issues, and other sensitive behaviors. For certain sections of

services among the civilian, noninstitutionalized population

the survey, in-person NSDUH interviews also used computer-

aged 12 or older in the United States. NSDUH estimates allow

assisted personal interviewing (CAPI), in which interviewers

researchers, clinicians, policymakers, and the general public to

read less sensitive questions to respondents and entered the

better understand and improve the nation’s behavioral health.

respondents’ answers into a NSDUH laptop computer.

Based on 2020 and earlier NSDUH data, this report

From January to March 2020, screening was completed at

contains findings on key substance use and mental health

35,304 addresses, and 15,628 completed interviews were

indicators in the United States. Te 2020 NSDUH detailed

obtained, including 3,936 interviews from adolescents aged

tables showing comprehensive substance use and mental

12 to 17 and 11,692 interviews from adults aged 18 or older.

health-related estimates are available separately at https://

Weighted response rates for household screening and for

www.samhsa.gov/data/.⁵

interviewing were 67.8 and 63.2 percent, respectively, for an

overall response rate of 42.9 percent for people aged 12 or

Survey Background

older. Te weighted interview response rates were 70.5 percent

for adolescents and 62.5 percent for adults.⁷ In-person data

NSDUH is an annual survey sponsored by SAMHSA

collection was suspended on March 16, 2020, because of the

within the U.S. Department of Health and Human Services

coronavirus disease 2019 (COVID-19) pandemic.

(HHS). NSDUH covers residents of households and

people in noninstitutional group settings (e.g., shelters,

Changes to Data Collection Methods Because of the

boarding houses, college dormitories, migratory workers’

COVID-19 Pandemic

camps, halfway houses). Te survey excludes people with

no fixed address (e.g., people who are homeless and not in

To protect the safety of field staff and survey participants

shelters), military personnel on active duty, and residents

during the COVID-19 pandemic, SAMHSA decided to

of institutional group settings, such as jails, nursing homes,

suspend in-person NSDUH data collection on March

mental health institutions, and long-term care hospitals.

16, 2020. With administrative approval, a small-scale

data collection effort was conducted from July 16 to 22,

Data Collection in the First Quarter of 2020

2020, to assess the feasibility of safely resuming in-person

data collection. Te small-scale data collection effort was

NSDUH employs a stratified multistage area probability

conducted in selected counties of two states where data

sample designed to be representative of both the nation as

collection was deemed safe based on state- and county-level

a whole and for each of the 50 states and the District of

COVID-19 metrics collected by Johns Hopkins University.⁸

Columbia. Te 2020 NSDUH target sample of 67,500

For the remainder of 2020, however, it became clear that

people was allocated across three age groups, with 25 percent

conventional in-person data collection would be severely

allocated to adolescents aged 12 to 17, 25 percent allocated

limited due to the COVID-19 pandemic.

to young adults aged 18 to 25, and 50 percent allocated to

adults aged 26 or older.⁶

To reduce the impact on NSDUH data collection due to

the COVID-19 pandemic, SAMHSA approved the addition

From January to March 2020 (i.e., the first quarter of

of web-based data collection on September 11, 2020. In

2020), NSDUH was a face-to-face household interview

Quarter 4 of 2020 (i.e., October to December), web-based

survey conducted in two phases: the screening phase and

screening and interviewing became the primary forms of

the interview phase. Interviewers conducted a screening of a

NSDUH data collection. Conventional in-person data

sampled household with an adult resident (aged 18 or older)

Key Substance Use and Mental Health Indicators in the United States:

8 | October 2021

Results from the 2020 National Survey on Drug Use and Health

collection was carried out wherever it was considered safe to

Because some estimates in Appendix A may not be found

do so based on county- and state-level COVID-19 metrics.⁶

in the detailed tables, Appendix A’s tables include standard

errors for the associated estimates.

In July 2020 for a small number of interviews, and

principally in October to December 2020, screening was

Te COVID-19 pandemic has made 2020 a unique year

completed for 55,633 addresses, and 20,656 completed

within the history of NSDUH. Estimates for most measures

interviews were obtained, including 2,401 interviews from

have been calculated using data from Quarters 1 and 4 of

adolescents aged 12 to 17 and 18,255 interviews from adults

2020. As mentioned previously, except for a very brief data

aged 18 or older. Weighted response rates for household

collection effort that tested increased safety measures in

screening and for interviewing were 11.1 and 59.5 percent,

July, no data were collected in Quarters 2 and 3 (i.e., April

respectively, for an overall response rate of 6.6 percent for

to September). Te difference in data collection methods

people aged 12 or older. Te weighted interview response

between Quarter 1 and Quarter 4 affected the procedures for

rates were 25.6 percent for adolescents and 62.9 percent for

weighting the 2020 data to produce national estimates.⁶

adults.⁷ Approximately 93 percent of these interviews were

With the introduction of web-based interviewing, data

completed via the web because of limitations on where it was

processing took into account the potential effects of

considered safe to conduct interviews in person.

survey mode¹⁵ on responses.¹⁰ In addition, questions were

Altogether for 2020, then, screening was completed for 90,937

developed to assess the specific effects of the COVID-19

addresses, and the final sample consisted of 36,284 completed

pandemic on respondents. Because these questions were

interviews. Tere were 6,337 interviews from adolescents

asked of respondents only in Quarter 4, only data from

aged 12 to 17 and 29,947 interviews from adults aged 18 or

Quarter 4 are available for these estimates. Sections of the

older. Weighted response rates for household screening and

report indicate when estimates use data from Quarter 4 only.

for interviewing were 25.7 and 60.4 percent, respectively, for

Otherwise, the default for the report is to present estimates

an overall response rate of 15.5 percent for people aged 12 or

using data from Quarters 1 and 4.¹⁶

older. Te weighted interview response rates were 36.8 percent

for adolescents and 62.8 percent for adults.7,9

Interpretation of Estimates for 2020

NSDUH underwent some major methodological changes

Further information about the 2020 NSDUH design and

for 2020. As noted previously, the COVID-19 pandemic

methods can be found on the web at https://www.samhsa.

necessitated the introduction of web-based interviewing.

gov/data/.¹⁰

In addition, 2020 marked the first year in which SUDs

were evaluated using criteria defined in the Diagnostic

Data Presentation and Interpretation

and Statistical Manual of Mental Disorders, 5th edition

Tis report focuses on substance use and mental health

(DSM-5),¹⁷ as opposed to criteria specified in the

indicators in the United States based on NSDUH data

Diagnostic and Statistical Manual of Mental Disorders, 4th

from 2020 and earlier years.¹¹ Estimates of substance use

edition (DSM-IV).¹⁸ Tere were additional changes to

and related treatment are presented for people aged 12 or

the questionnaire itself (e.g., new questions about vaping

older, including adolescents and adults.¹² However, estimates

and the use of synthetic marijuana or synthetic stimulants,

of mental health issues and mental health service use are

additional questions to measure SUDs based on the DSM-5

presented separately for adolescents aged 12 to 17 and adults

criteria, new questions in Quarter 4 to assess the impact of

aged 18 or older because the two groups completed different

COVID-19 on people’s lives). Finally, there was a significant

sets of questions regarding mental health and mental health

gap in data collection that might have missed seasonality

service utilization. All estimates (e.g., percentages and

effects on some estimates. Terefore, care must be taken

numbers) presented in the report are derived from survey

when attempting to disentangle the effects on estimates

data that are subject to sampling errors and have met the

due to real changes in the population (e.g., the COVID-19

criteria for statistical precision.¹³

pandemic, other events) from these methodological changes.

Researchers have raised concerns that the COVID-19

Presentation of National Estimates for 2020

pandemic could have negative effects on substance use and

Appendix A contains special tables of estimates, including

mental health outcomes.19,20,21 However, the methodological

estimates not found in the 2020 NSDUH detailed tables.

changes for the 2020 NSDUH also can affect the 2020

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

estimates. Terefore, direct comparison of NSDUH

can or a bottle of beer, a glass of wine or a wine cooler,

estimates in 2020 with those from prior years can be

a shot of liquor, or a mixed drink with liquor in it). Past

misleading. An additional caveat is that events in the United

month illicit drug use includes any use of marijuana,

States related to the COVID-19 pandemic were not the only

cocaine (including crack), heroin, hallucinogens, inhalants,

ones in 2020 that could have affected people’s substance

or methamphetamine, as well as misuse of prescription

use and mental health. To that end, NSDUH estimates

stimulants, tranquilizers or sedatives (e.g., benzodiazepines),

principally describe conditions in the population but may not

or pain relievers. (See the section on the Misuse of

explain the reasons behind the estimates.

Psychotherapeutic Drugs for the definition of “misuse.”)

Statistical tests for comparisons are presented in this

Tables in Appendix A also include estimates of past

report where appropriate. Of note, statistical testing was

month use for the following other substances: gamma

performed for comparisons of estimates across age groups

hydroxybutyrate (GHB), the misuse of nonprescription

within 2020.²² In these instances, statistically significant

cold and cough medicine, kratom, synthetic marijuana (fake

differences resulting from this testing are described using

weed, K2, or Spice), and synthetic stimulants (“bath salts”

terms such as “higher” or “lower.” Statements use terms

or flakka). Estimates for the use or misuse of these other

such as “similar” or “the same” when a difference was not

substances are discussed later in the report for the past year

statistically significant. However, the methodological changes

(rather than the past month) because of low prevalence

in 2020 because of the COVID-19 pandemic have created

estimates in the past month for many of these substances.

major challenges for survey researchers and other data users

Among people aged 12 or older in 2020, 58.7 percent (or

in interpreting estimates from the 2020 NSDUH. Particular

162.5 million people) used tobacco, alcohol, or an illicit drug

caution must be taken for multiyear trend analysis and the

in the past month, 50.0 percent (or 138.5 million people)

comparison of the results from 2020 with those from any

drank alcohol in the past month, 18.7 percent (or 51.7 million

prior survey years. Efforts were made to present the results

people) used a tobacco product in the past month, and

by defining measures for 2020 consistently with measures

13.5 percent (or 37.3 million people) used an illicit drug in the

in previous years wherever possible. Meanwhile, efforts were

past month (Figure 1 and Table A.1B). Estimates for tobacco,

also made to point out the uniqueness of 2020 and the need

alcohol, or illicit drugs are not mutually exclusive because

for caution when making comparisons.

respondents could have used more than one type of substance

(e.g., tobacco products and alcohol) in the past month.

General Substance Use in the Past Month

Figure 1. Past Month General Substance Use and Nicotine Vaping:

Tis section provides an overview of estimates according

Among People Aged 12 or Older; 2020

to whether respondents aged 12 or older reported using

nicotine products (using tobacco products or nicotine

vaping), alcohol, or illicit drugs in the 30 days before the

NSDUH interview (i.e., in the past month, also referred to

as “current use”). Due to the very small amount of data that

are available from April to September 2020, caution must

be taken when interpreting estimates of substance use in the

past month. Additional information on the use of tobacco

products, alcohol, and illicit drugs is provided in other

sections of this report.¹⁴

Past month tobacco use includes any use of the four tobacco

products in NSDUH: cigarettes, smokeless tobacco (such

as snuff, dip, chewing tobacco, or snus), cigars, and pipe

tobacco. Past month nicotine vaping refers to the use of

Rx = prescription.

an e-cigarette or other vaping device to vape nicotine or

Note: General Substance Use includes any illicit drug, alcohol, and tobacco product use. Tobacco

tobacco. Past month alcohol use refers to having more

products are defined as cigarettes, smokeless tobacco, cigars, and pipe tobacco.

than a sip or two of any type of alcoholic drink (e.g., a

Note: The estimated numbers of current users of different substances are not mutually exclusive

because people could have used more than one type of substance in the past month.

Key Substance Use and Mental Health Indicators in the United States:

10 | October 2021

Results from the 2020 National Survey on Drug Use and Health

Tobacco Use or Nicotine Vaping in the

interpreting estimates in this section due to the very small

amount of data that are available from April to September.

Past Month

Before 2020, NSDUH assessed tobacco use but did not

As noted in the section on General Substance Use in the Past

include questions on nicotine vaping. However, recent

Month, past month tobacco use in NSDUH includes any use

increases in nicotine vaping have resulted in changes in

of four tobacco products: cigarettes, smokeless tobacco (such as

adolescent tobacco use. Findings from the 2019 National

snuff, dip, chewing tobacco, or snus), cigars, and pipe tobacco.

Youth Tobacco Survey (NYTS) and the 2019 Monitoring

Past month nicotine vaping refers to the use of an e-cigarette

the Future (MTF) study indicated increases in nicotine

or other vaping device to vape nicotine or tobacco. Aggregate

vaping.23,24,25 NYTS data indicate that e-cigarettes have

estimates for the past month use of tobacco or nicotine vaping

been the most commonly used nicotine product among

(also referred to as current use of nicotine products) are

youths since 2014, including in 2020, and that e-cigarette

presented for people who used any of these tobacco products

use has reached epidemic proportions among youths.²⁵ In

or vaped nicotine in the past month (or both).

addition, vaping of nicotine products among adolescents

Among people aged 12 or older in 2020, 20.7 percent

has been identified as a risk factor for future cigarette use,²⁴

(or 57.3 million people) used tobacco products or vaped

which may affect long-term cigarette use trends. However,

nicotine in the past month (Figure 2 and Table A.1B). Te

the 2020 MTF study found similar estimates between 2019

percentage of people who used tobacco products or vaped

and 2020 in nicotine vaping in the past month among 8th,

nicotine in the past month was highest among young adults

10th, and 12th graders.²⁶ Te 2020 NYTS also indicated

aged 18 to 25 (25.1 percent or 8.4 million people), followed

a reversal of previous trends, with e-cigarette use among

by adults aged 26 or older (21.6 percent or 47.2 million

adolescents declining from 2019 to 2020 and returning to

people), then by adolescents aged 12 to 17 (6.5 percent or

levels similar to those in 2018. Nevertheless, e-cigarette use

1.6 million people) (Tables A.2B to A.4B).

remained the most common form of nicotine product use

Among current nicotine product users, the use of specific

among adolescents in the 2020 NYTS. Despite the decline

nicotine products varied by age group. Nearly two thirds of

in e-cigarette use between 2019 and 2020, NYTS researchers

adolescents aged 12 to 17 who used nicotine products in the

stressed the need for continued effort to sustain this apparent

past month (63.1 percent) vaped nicotine but did not use

progress.²⁷ An issue with the MTF and NYTS data for 2020

tobacco products (Table A.5B). An additional 15.7 percent

is that sample sizes were smaller in 2020. School closures in

of adolescents who used nicotine products in the past month

the spring in response to the COVID-19 pandemic led to

vaped nicotine and used tobacco products. About half of

the early conclusion of data collection for both surveys.26,27

young adults aged 18 to 25 who used nicotine products in

Te 2020 NSDUH included questions to assess the use

the past month (53.4 percent) used tobacco products but

of nicotine vaping in both adolescents and adults. As

did not vape nicotine, 23.6 percent vaped nicotine but did

noted previously, however, caution must be taken when

not use tobacco products, and 22.9 percent vaped nicotine

Figure 2. Past Month Tobacco Use and Nicotine Vaping: Among People Aged 12 or Older; 2020

Note: The estimated numbers of current users of different tobacco products or nicotine vaping are not mutually exclusive because people could have used more than one

type of tobacco product or used tobacco products and vaped nicotine in the past month.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

and used tobacco products. Among adults aged 26 or older

24.9 million people (or 60.1 percent) were daily cigarette

who used nicotine products in the past month, however,

smokers (Figure 4), and 9.4 million people (or 37.8 percent)

88.9 percent used only tobacco products.

smoked 16 or more cigarettes per day (i.e., approximately

one pack or more per day). Among current cigarette

Tobacco Product Use

smokers, adults aged 26 or older were more likely than

In 2020, of the 51.7 million current (i.e., past month)

young adults aged 18 to 25 to be daily smokers (64.1 vs.

tobacco users (Figure 1), the majority were current cigarette

33.1 percent) (Tables A.3B and A.4B).

smokers (41.4 million; Figure 2). Tis pattern has been the

Nicotine Vaping

case historically.²⁸ Additionally, 10.6 million people were

current cigar smokers, 7.0 million people were current

In 2020, 10.4 million people aged 12 or older (or 3.8 percent)

smokeless tobacco users, and 1.8 million people were current

used an e-cigarette or other vaping device to vape nicotine in

pipe tobacco smokers.

the past month (Figures 2 and 5). Te percentage of people

who vaped nicotine was highest among young adults aged 18 to

Among people aged 12 or older in 2020 who used any

25 (11.7 percent or 3.9 million people), followed by adolescents

tobacco product in the past month (regardless of whether

aged 12 to 17 (5.1 percent or 1.3 million people), then by

they vaped nicotine), 65.3 percent smoked cigarettes but

adults aged 26 or older (2.4 percent or 5.2 million people).

did not use other tobacco products, 14.8 percent smoked

cigarettes and used some other type of tobacco product, and

Underage Tobacco Use or Nicotine Vaping

19.9 percent used only noncigarette tobacco products (i.e.,

other tobacco products but not cigarettes) (Table A.6B).

Legislation in December 2019 amending the Federal Food,

Among adults who used tobacco products in the past month,

Drug, and Cosmetic Act raised the federal minimum age

adults aged 26 or older were more likely than young adults

for sale of tobacco products (including e-cigarettes) from

aged 18 to 25 to have used only cigarettes in the past month

(68.0 vs. 49.3 percent). However, the majority of young

Figure 3. Past Month Cigarette Use: Among People Aged 12 or

adults who were past month tobacco users smoked cigarettes,

Older; 2002-2020

either as the only tobacco product they used or in addition

to other tobacco products. Estimates among adolescents aged

12 to 17 who used tobacco products in the past month could

not be calculated with sufficient precision for the use of only

cigarettes or the use of only noncigarette tobacco products.

Te remainder of this section on tobacco use focuses on

cigarette smoking because most current tobacco users aged

12 or older were cigarette smokers. Information on the

use of cigars, pipe tobacco, and smokeless tobacco in the

past month among people aged 12 or older and by age group

02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

can be found in Tables A.1B to A.4B in Appendix A.

Years

Age Category:

12 or Older

12 to 17

18 to 25

26 or Older

Cigarette Use

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

Among people aged 12 or older in 2020, 15.0 percent (or

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

41.4 million people) smoked cigarettes in the past month

(Figure 3). Te percentage of people who smoked cigarettes

Figure 3 Table. Past Month Cigarette Use: Among People Aged 12 or Older;

2002-2020

in the past month was highest among adults aged 26 or older

(16.7 percent or 36.4 million people), followed by young

Age

adults aged 18 to 25 (13.9 percent or 4.7 million people), then

≥12

26.0

25.4

24.9

25.0

24.3

24.0

23.3

23.0

22.1

21.3

20.8

19.4

19.1

17.9

17.2

16.7

15.0

12-17

13.0

12.2

11.9

10.8

10.4

9.9

9.2

9.0

8.4

7.8

6.6

5.6

4.9

4.2

3.4

3.2

2.7

2.3

1.4

by adolescents aged 12 to 17 (1.4 percent or 350,000 people).

18-25

40.8

40.2

39.5

39.0

38.5

36.2

35.7

35.8

34.3

33.5

31.8

30.6

28.4

26.7

23.5

22.3

19.1

17.5

13.9

≥26

25.2

24.7

24.1

24.3

24.7

24.1

23.8

23.0

22.8

21.9

22.4

21.6

21.5

20.0

20.2

18.9

18.5

18.2

16.7

Daily Cigarette Use

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates

Among the 41.4 million current cigarette smokers aged

between 2020 and prior years because of methodological changes for 2020. Due to these changes,

12 or older in 2020 (see the section on Cigarette Use),

significance testing between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

12 | October 2021

Results from the 2020 National Survey on Drug Use and Health

Figure 4. Daily Cigarette Use: Among Past Month Cigarette Smokers Aged 12 or Older;

Smoking of One or More Packs of Cigarettes per Day: Among Current Daily Smokers; 2020

Note: Current daily smokers with unknown data about the number of cigarettes smoked per day were excluded from the pie chart on the right.

18 to 21 years.²⁹ All 50 states and the District of Columbia now

in the past 30 days, which has remained unchanged from

prohibit the sale of tobacco products to people younger than 21.

the threshold prior to 2015. Since 2015, binge alcohol use

for females has been defined as drinking four or more drinks

Among people aged 12 to 20, 11.8 percent (or 4.4 million

on the same occasion on at least 1 day in the past 30 days.³¹

people) used tobacco products or used an e-cigarette or other

Tis definition of binge alcohol use is consistent with federal

vaping device to vape nicotine (Table A.7B). Among people

definitions.³² Heavy alcohol use was defined as binge drinking

in this age group, 7.7 percent (or 2.9 million people) vaped

on 5 or more days in the past 30 days based on the thresholds

nicotine, 6.7 percent (or 2.5 million people) used tobacco

described previously for males and females. Also, as noted

products, and 4.1 percent (or 1.5 million people) smoked

previously, caution must be taken when interpreting estimates

cigarettes in the past month.

of alcohol use in the past month due to the very small amount

of data that are available from April to September.

Figure 5. Past Month Nicotine Vaping: Among People Aged 12 or

Older; 2020

Among the 138.5 million current alcohol users aged 12 or

older in 2020, 61.6 million people (or 44.4 percent) were

past month binge drinkers (Figure 6). Among past month

Figure 6. Current, Binge, and Heavy Alcohol Use: Among People

Aged 12 or Older; 2020

Alcohol Use in the Past Month

As noted in the section on General Substance Use in the Past

Month, the 2020 NSDUH asked respondents aged 12 or older

about their alcohol use in the 30 days before the interview. In

addition to asking about any alcohol use, NSDUH collected

information on past month binge alcohol use and heavy

Note: Binge Alcohol Use is defined as drinking five or more drinks (for males) or four or more drinks

alcohol use. Binge drinking for males was defined as drinking

(for females) on the same occasion on at least 1 day in the past 30 days. Heavy Alcohol Use is

defined as binge drinking on the same occasion on 5 or more days in the past 30 days; all heavy

five or more drinks³⁰ on the same occasion on at least 1 day

alcohol users are also binge alcohol users.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

binge drinkers, 17.7 million people (28.8 percent of current

Heavy Alcohol Use

binge drinkers and 12.8 percent of current alcohol users)

Among people aged 12 or older in 2020, 6.4 percent

were past month heavy drinkers.³³

(or 17.7 million people) were heavy alcohol users in

the past month (Figures 6 and 8). Te percentage was

Any Alcohol Use

highest among young adults aged 18 to 25 (8.6 percent or

Among people aged 12 or older in 2020, 50.0 percent (or

2.9 million people), followed by adults aged 26 or older

138.5 million people) drank alcohol in the past month

(6.7 percent or 14.7 million people), then by adolescents

(Figure 6 and Table A.1B). Te percentage was highest

aged 12 to 17 (0.6 percent or 140,000 people).

among adults aged 26 or older (54.6 percent or 119.2 million

people), followed by young adults aged 18 to 25 (51.5 percent

Underage Alcohol Use

or 17.3 million people), then by adolescents aged 12 to 17

As of 2020, all 50 states and the District of Columbia prohibited

(8.2 percent or 2.1 million people) (Tables A.2B to A.4B).

the possession of alcoholic beverages by people younger than

21 (although some states may have had exceptions). Most states

Binge Alcohol Use

also prohibited underage consumption (i.e., consumption of

Among people aged 12 or older in 2020, 22.2 percent

alcoholic beverages prior to the age of 21).³⁴ Among people

(or 61.6 million people) were binge alcohol users in the

aged 12 to 20 in 2020, 16.1 percent (or 6.0 million people)

past month (Figures 6 and 7). Te percentage was highest

were past month alcohol users (Table A.7B). Estimates of binge

among young adults aged 18 to 25 (31.4 percent or

alcohol use and heavy alcohol use in the past month among

10.5 million people), followed by adults aged 26 or older

underage people were 9.2 percent (or 3.4 million people) and

(22.9 percent or 50.0 million people), then by adolescents

1.8 percent (or 669,000 people), respectively.

aged 12 to 17 (4.1 percent or 1.0 million people).

Figure 7. Past Month Binge Alcohol Use: Among People Aged 12

Figure 8. Past Month Heavy Alcohol Use: Among People Aged 12

or Older; 2015-2020

2015

2016

2017

2018

2019

2020

2015

2016

2017

2018

2019

2020

Years

Age Category:

12 or Older

12 to 17

18 to 25

26 or Older

Age Category:

12 or Older

12 to 17

18 to 25

26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 7 Table. Past Month Binge Alcohol Use: Among People Aged 12 or

Figure 8 Table. Past Month Heavy Alcohol Use: Among People Aged 12 or

Older; 2015-2020

Age

2015

2016

2017

2018

2019

2020

Age

2015

2016

2017

2018

2019

2020

12 or Older

24.9

24.2

24.5

23.9

22.2

12 or Older

6.5

6.0

6.1

5.8

6.4

12 to 17

5.8

4.9

5.3

4.7

4.9

4.1

12 to 17

0.9

0.8

0.7

0.5

0.8

0.6

18 to 25

39.0

38.4

36.9

34.9

34.3

31.4

18 to 25

10.9

10.1

9.6

9.0

8.4

8.6

26 or Older

24.8

24.2

24.7

25.1

24.5

22.9

26 or Older

6.4

6.0

6.2

6.0

6.7

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

14 | October 2021

Results from the 2020 National Survey on Drug Use and Health

Illicit Drug Use in the Past Year

Marijuana Use

Te 2020 NSDUH obtained illicit drug use information

In 2020, 17.9 percent of people aged 12 or older (or

for the use of marijuana, cocaine (including crack), heroin,

49.6 million people) used marijuana in the past year

hallucinogens, inhalants, and methamphetamine, as well

(Figures 9 and 11). Te percentage was highest among

as for the misuse of prescription stimulants, tranquilizers,

young adults aged 18 to 25 (34.5 percent or 11.6 million

sedatives,³⁵ and pain relievers (see the section on the Misuse of

Psychotherapeutic Drugs for the definition of “misuse”). Tis

Figure 10. Past Year Illicit Drug Use: Among People Aged 12 or

Older; 2015-2020

report presents estimates of past year (rather than past month)

illicit drug use because of low prevalence estimates for some

illicit drugs (e.g., heroin). Moreover, the 2020 NSDUH

collected only past year (rather than past month) data on

the misuse of benzodiazepines and specific subtypes of

prescription pain relievers (e.g., fentanyl products).

Among people aged 12 or older in 2020, 59.3 million

people used illicit drugs in the past year (Figure 9). Te most

commonly used illicit drug in the past year was marijuana,

which was used by 49.6 million people. Te second most

common type of illicit drug use in the past year was the

misuse of prescription pain relievers, which were misused by

9.3 million people. Smaller numbers of people were past year

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

users of other illicit drugs, as shown in Figure 9.³⁶

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Any Illicit Drug Use

Figure 10 Table. Past Year Illicit Drug Use: Among People Aged 12 or Older;

2015-2020

Among people aged 12 or older in 2020, 21.4 percent

(or 59.3 million people) used illicit drugs in the past year

Age

2015

2016

2017

2018

2019

2020

(Figures 9 and 10). Te percentage was highest among

12 or Older

17.8

18.0

19.0

19.4

20.8

21.4

12 to 17

17.5

15.8

16.3

16.7

17.2

13.8

young adults aged 18 to 25 (37.0 percent or 12.4 million

18 to 25

37.5

37.7

39.4

38.7

39.1

37.0

people), followed by adults aged 26 or older (19.9 percent

26 or Older

14.6

15.0

16.1

16.7

18.3

19.9

or 43.4 million people), then by adolescents aged 12 to 17

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

(13.8 percent or 3.4 million people).

between 2020 and prior years was not performed.

Figure 9. Past Year Illicit Drug Use: Among People Aged 12 or Older; 2020

Marijuana

49.6M

Rx Pain Reliever Misuse

9.3M

Hallucinogens

7.1M

Rx Tranquilizer or Sedative Misuse

6.2M

No Past Year

Past Year

Cocaine

5.2M

Illicit Drug Use

Rx Stimulant Misuse

5.1M

217.6 Million People

59.3 Million People

(78.6%)

(21.4%)

Methamphetamine

2.5M

Inhalants

2.4M

Heroin

902,000

Number of Past Year Users

Rx = prescription.

Note: The estimated numbers of past year users of different illicit drugs are not mutually exclusive because people could have used more than one type of illicit drug in the past year.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

October 2021

people), followed by adults aged 26 or older (16.3 percent

Heroin Use

or 35.5 million people), then by adolescents aged 12 to 17

Among people aged 12 or older in 2020, 0.3 percent (or

(10.1 percent or 2.5 million people).

902,000 people) used heroin in the past year (Figure 9

and Table A.12B). Estimates of past year heroin use were

Cocaine Use

0.2 percent (or 62,000 people) among young adults aged

Cocaine use includes the use of crack cocaine. Estimates of

18 to 25 and 0.4 percent (or 840,000 people) among adults

crack use are presented separately as well. Among people

aged 26 or older (Tables A.14B and A.15B). Estimates of

aged 12 or older in 2020, 1.9 percent (or 5.2 million people)

past year heroin use among adolescents aged 12 to 17 could

used cocaine in the past year (Figure 9 and Table A.12B).

not be calculated with sufficient precision (Table A.13B).

Te percentage was highest among young adults aged 18 to

25 (4.3 percent or 1.4 million people), followed by adults

Methamphetamine Use

aged 26 or older (1.7 percent or 3.6 million people), then

Although methamphetamine is legally available by

by adolescents aged 12 to 17 (0.3 percent or 84,000 people)

prescription (Desoxyn®), most methamphetamine used in

(Tables A.13B to A.15B).

the United States is produced and distributed illicitly rather

In 2020, an estimated 0.2 percent of people aged 12 or

than through the pharmaceutical industry. Terefore, the

older (or 657,000 people) used crack in the past year. Te

2015 to 2020 NSDUHs have included separate sections

percentage was lowest among adolescents aged 12 to 17

for methamphetamine use and the use and misuse of

(less than 0.1 percent or 2,000 people). Tis percentage

prescription stimulants.

increased with age (0.1 percent of young adults aged 18 to 25

Among people aged 12 or older in 2020, 0.9 percent (or

or 49,000 people; 0.3 percent of adults aged 26 or older or

2.5 million people) used methamphetamine in the past year

606,000 people).

(Figures 9 and 12). Adolescents aged 12 to 17 had the lowest

Figure 11. Past Year Marijuana Use: Among People Aged 12 or

Figure 12. Past Year Methamphetamine Use: Among People Aged

Older; 2002-2020

12 or Older; 2015-2020

02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

Years

Age Category:

12 or Older

12 to 17

18 to 25

26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 11 Table. Past Year Marijuana Use: Among People Aged 12 or Older;

Figure 12 Table. Past Year Methamphetamine Use: Among People Aged 12 or

2002-2020

Older; 2015-2020

Age

2015

2016

2017

2018

2019

2020

≥12

11.0

10.6

10.4

10.3

10.1

10.4

11.4

11.6

11.5

12.1

12.6

13.2

13.5

13.9

15.0

15.9

17.5

17.9

12 or Older

0.6

0.5

0.6

0.7

0.9

12-17

15.8

15.0

14.5

13.3

13.2

12.5

13.1

13.7

14.0

14.2

13.5

13.4

13.1

12.6

12.0

12.4

12.5

13.2

10.1

12 to 17

0.2

0.1

0.2

0.1

18-25

29.8

28.5

27.8

28.0

28.1

27.5

27.8

30.8

30.0

30.8

31.5

31.6

31.9

32.2

33.0

34.9

34.8

35.4

34.5

18 to 25

0.9

0.8

1.1

0.8

0.5

≥26

7.0

6.9

7.0

6.9

6.8

7.0

7.7

8.0

7.9

8.6

9.2

10.1

10.4

11.0

12.2

13.3

15.2

16.3

26 or Older

0.6

0.5

0.6

0.7

0.8

1.1

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

16 | October 2021

Results from the 2020 National Survey on Drug Use and Health

estimate of past year methamphetamine use (0.1 percent or

polish, correction fluids, felt-tip markers), aerosols (e.g., spray

21,000 people). Percentages increased with age (0.5 percent

paints, deodorant and hair sprays, fabric protector sprays,

of young adults aged 18 to 25 or 171,000 people;

computer keyboard cleaner), gases (e.g., ether, halothane,

1.1 percent of adults aged 26 or older or 2.4 million people).

nitrous oxide, butane, propane), and nitrites (e.g., amyl

nitrite, “poppers,” locker room deodorizers, “rush”). NSDUH

Hallucinogen Use

respondents were asked to report the use of inhalants to get

Several drugs are grouped under the category of hallucinogens,

high but not to include accidental inhalation of a substance.

including LSD, PCP, peyote, mescaline, psilocybin

Among people aged 12 or older in 2020, 0.9 percent (or

mushrooms, “Ecstasy” (MDMA or “Molly”), ketamine,

2.4 million people) used inhalants in the past year (Figures 9

DMT/AMT/“Foxy,” and Salvia divinorum.³⁷ In 2020,

and 14). Unlike other illicit drug use estimates, the percentage

2.6 percent of people aged 12 or older (or 7.1 million people)

was highest among adolescents aged 12 to 17 (2.7 percent or

used hallucinogens in the past year (Figures 9 and 13). Te

683,000 people). Percentages decreased with age (1.5 percent

percentage among young adults aged 18 to 25 (7.3 percent or

of young adults aged 18 to 25 or 507,000 people; 0.5 percent

2.4 million people) was higher than the percentages among

of adults aged 26 or older or 1.2 million people).

adolescents aged 12 to 17 (1.5 percent or 370,000 people) or

adults aged 26 or older (2.0 percent or 4.3 million people).

Misuse of Psychotherapeutic Drugs

Te 2020 NSDUH assessed the use and misuse of

Inhalant Use

psychotherapeutic drugs currently or recently available by

Inhalants include volatile solvents (e.g., paint thinners and

prescription in the United States, including prescription

removers, dry cleaning fluids, degreasers, gasoline, glues, shoe

stimulants, tranquilizers or sedatives (e.g., benzodiazepines),

Figure 13. Past Year Hallucinogen Use: Among People Aged 12 or

Figure 14. Past Year Inhalant Use: Among People Aged 12 or

Older; 2015-2020

Figure 13 Table. Past Year Hallucinogen Use: Among People Aged 12 or

Figure 14 Table. Past Year Inhalant Use: Among People Aged 12 or Older;

Older; 2015-2020

2015-2020

Age

2015

2016

2017

2018

2019

2020

Age

2015

2016

2017

2018

2019

2020

12 or Older

1.8

1.9

2.0

2.2

2.6

12 or Older

0.7

0.6

0.7

0.8

0.9

12 to 17

2.1

1.8

2.1

1.5

1.8

1.5

12 to 17

2.7

2.2

2.3

2.7

3.0

2.7

18 to 25

7.0

6.9

7.0

6.9

7.2

7.3

18 to 25

1.4

1.6

1.5

1.7

1.5

26 or Older

0.8

1.0

1.3

1.5

2.0

26 or Older

0.3

0.4

0.5

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health - page 1