We’ve known for some time now that Americans are increasingly dying younger, but the scale and nature of the problem has been a little bit murky. There was speculation that the downturn in American life expectancy was all thanks to “deaths of despair,” but some experts have said that might not be the full story, and that obesity and tobacco are still major factors in American mortality.

A new study out today in the Journal of the American Medical Association drills down into which states are showing increases in deaths among the young, and why. In doing so, it reveals a profound disparity among the states when it comes to both life expectancy and disability.

Most startlingly, since 1990, 21 states have seen an increase in the death rate among people aged 20 to 55. In five states—Kentucky, Oklahoma, New Mexico, West Virginia, and Wyoming—the probability of early death among young adults rose by more than 10 percent in that time frame. Meanwhile, in New York and California, young and middle-aged people became much less likely to die in the same time period. The authors note that opioids, alcoholism, suicide, and kidney disease—which can be brought on by diabetes and alcoholism—were the main factors leading to the increases in early deaths.