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The surgeon general says loneliness is as deadly as smoking

A new report finds a lack of connection is killing us — and suggests ways to fix it.

A person sitting on an unmade bed, looking out the window.
A new US Surgeon General’s report warns America’s loneliness crisis is making people sicker.
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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

The US Surgeon General is sounding an alarm: Americans are more lonely and socially disconnected than ever, and it’s a serious threat to their physical and mental health that demands urgent policy action.

A new report from the Surgeon General says that social isolation’s effects on mortality are equivalent to smoking up to 15 cigarettes every day. Social isolation (an objective measure of lacking connection to families, friends, and community) and loneliness (a subjective measure of feeling disconnected) contribute to a person having a higher risk of heart disease, stroke, anxiety, depression, and dementia, and make people more susceptible to infectious diseases.

Those individual health effects ripple out into the broader community. Communities with more social cohesion have less disease and lower all-cause mortality than those with less so-called social capital. They are better prepared for natural disasters and experience less violence.

Reports from the surgeon general are reserved for urgent public health issues that require immediate action — and the nation’s top public health official argues that loneliness and isolation qualify.

“Given the profound consequences of loneliness and isolation, we have an opportunity, and an obligation, to make the same investments in addressing social connection that we have made in addressing tobacco use, obesity, and the addiction crisis,” Surgeon General Vivek Murthy wrote in the opening of the report.

The advisory breaks down the measures of social isolation and loneliness in the US, how they can affect people’s health, and introduces recommendations about how to being to alleviate this epidemic of loneliness. Here are the report’s main takeaways.

1) Americans are lonelier and more isolated than ever

Americans are experiencing more loneliness and isolation than at any time in recent memory. Those trends were already underway well before the Covid-19 pandemic, though living through three years of a public health crisis has likely accelerated them, at least for some people.

Half of Americans say they experience loneliness, according to several recent surveys: Less than 40 percent said in a 2022 study that they felt very connected to others.

Loneliness is subjective, and the report notes that a certain amount of solitude, even undesired solitude, can help people become more resilient. But more objective measures also reveal a country in which people are increasingly isolated from one another.

In the 1970s, almost half of Americans (45 percent) said they could generally trust other people, according to the surgeon general’s report. Today, less than a third say the same. The amount of time that Americans say they spend alone every day had risen by nearly 30 minutes from 2003 to 2019 and increased another 20-plus minutes in 2020, the first year of the pandemic, which amounted to almost an additional full day of solitude over the course of a month. The amount of time that young people (ages 15-24) spend with their friends in person dropped by nearly 70 percent from 2003 to 2020, as long-running trends got worse when the pandemic set in. Half of the country says they have three or fewer close friends, double the number from 1990. Just 16 percent of Americans say they feel very attached to their local community.

The causes for this increasing isolation are complex. People are less likely to get married and are having fewer children. Americans are much less likely to belong to religious organizations, a historical source of community connection. These are legitimate lifestyle choices. But, as the report notes, people need to be aware of the risks that loneliness brings to their health in order to better appreciate the need to seek out social connection.

Other risk factors for loneliness include being a racial or ethnic minority or identifying as LGBTQ, experiencing discrimination, having a lower income, and living alone. Being in poor physical or mental health is also associated with more isolation, suggesting a feedback loop in which loneliness not only contributes to poor health but perpetuates it. The percentage of households that comprise a single person living by themselves has doubled from 1960 to 2022, to the point that now nearly one in three Americans lives alone.

The role of technology in fostering loneliness has been scrutinized lately, but the report notes that the relationship is complex. Social media can create opportunities for people to connect with others, but it can also exacerbate loneliness. People who spend more than two hours a day on social media or who are the targets of online harassment report feeling more isolated from other people.

The pandemic likewise had a mixed effect on people’s connection to other people. About one in four Americans said they felt less close to their family at the beginning of Covid-19, but one in five said they felt more connected, an indication that perhaps “the pandemic exacerbated existing family dynamics of connection or disconnection,” according to the report.

What’s clear from the surgeon general’s report is that neither the pandemic nor technology should be seen as unique causes of this loneliness epidemic, but instead as accelerants. The broader social infrastructure — both cultural and physical — must be addressed in order to alleviate people’s isolation. Because it is quite literally killing them.

2) Loneliness and social isolation negatively affect a person’s and a community’s health

How does isolation affect a person’s physical and mental health? The relationship is once again multifold: physical, psychological, and behavioral.

Isolation can lead to a person experiencing a higher amount of stress, which affects mental well-being as well as causing the body to release stress hormones. Those hormones can contribute to higher levels of inflammation, which is associated with a wide spectrum of health problems. People with stronger social connections are also more likely to behave in ways that lead to better health: more physical activity, better nutrition, and even better management of chronic diseases.

The empirical evidence is consistent: More social connection is linked with better health outcomes and vice versa. The surgeon general’s report notes that one of the first large-scale epidemiological studies, conducted in the late 1970s, found that people with a low amount of social connection were more than twice as likely to die during the study period as people with high social connection, even after adjusting for age, health, and economic status. A more recent systemic review of the available research also found that a high level of social connection led people to be 50 percent more likely to survive over a long follow-up period, which averaged 7.5 years across the nearly 150 studies included in the review.

As the report concluded in one of its most striking passages:

Indeed, the effects of social connection, isolation, and loneliness on mortality are comparable, and in some cases greater, than those of many other risk factors including lifestyle factors (e.g., smoking, alcohol consumption, physical inactivity), traditional clinical risks factors (e.g., high blood pressure, body mass index, cholesterol levels), environmental factors (e.g., air pollution), and clinical interventions (e.g., flu vaccine, high blood pressure medication, rehabilitation).

Social isolation is associated with higher rates of heart disease, stroke, hypertension, and diabetes. People with stronger social connections are correspondingly less likely to be readmitted to a hospital after being treated for heart failure and they are generally better at managing chronic conditions like diabetes than people who are more isolated.

Loneliness also comes with the expected effects on a person’s mental well-being. More isolation is linked to higher rates of anxiety, depression, and self-harm, even if once again the report cautions that these outcomes have complicated origins. But the connection is unavoidable: One study found that men who live alone are twice as likely to die by suicide.

These trends apply not only at the individual level, but also to entire communities. Communities with higher social capital — which can be linked to family structure and involvement, trust in community institutions, popularity of volunteerism, levels of participation in political discussions and voting efforts, and cohesion among community members — experience better health.

One study found that a 10 percent increase in the number of people in an area who say they feel connected to others was associated with an 8 percent drop in all-cause mortality. A county-level analysis of deaths during the Covid-19 pandemic found that “lower levels of social capital were associated with a higher number of cases and deaths from COVID-19 infection,” the report noted.

Those population-level effects trickle down to communities with more social cohesion having better experiences during natural disasters (in part because of better preparation) and seeing less violence.

3) How the US can begin to address its loneliness epidemic

So the problem is clear. Objectively and subjectively, Americans are more isolated and lonely than ever. That isolation leads to worse health outcomes at both the individual and community level.

So what do we do about it? The Surgeon General’s office sketches out the principles upon which a successful strategy to alleviate the US loneliness epidemic could be built.

The underlying causes here span from the individual (chronic diseases, personality, socioeconomic status) to the relational (household, quality of interpersonal relationships) to the community (outdoor spaces, community organizations, health systems) to the societal (norms and values, civic engagement, historical inequities).

The report includes a long appendix with recommendations targeted to specific organizations at different levels of society, from the government (federal, state, and local) to individual physicians, academics, schools, employers, and even the media.

But in broad strokes, the report recommends six pillars for making Americans feel more connected and less isolated from one another:

  1. Strengthen the social infrastructure: more communal spaces, more social activities, and better infrastructure to help people access them
  2. Develop “pro-connection” public policies that account for the need to foster connection when passing laws or formulating regulations, from transportation to education to housing
  3. Mobilize the health sector: train health care providers to identify people at risk of isolation and better equip providers to connect patients with the other forms of social support they may need
  4. Reform digital environments: require more transparency from large tech companies and establish safeguards (such as restrictions for young people) that could ameliorate the worst effects of social media on vulnerable populations
  5. Deepen our knowledge: support academic research and public information campaigns to improve our understanding of the connections between isolation and health and make people more aware of the problem in the first place
  6. Cultivate a culture of connection: use all of the vectors available, from politics to entertainment, to reinforce the values of connection and reduce the polarization that can lead to people feeling more isolated in our modern age

These are enormous and daunting undertakings. But they are necessary, given the scale of the challenge before the country.

“We are called to build a movement to mend the social fabric of our nation,” Murthy wrote. “It will take all of us ... working together to destigmatize loneliness and change our cultural and policy response to it.”

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