(Initiation of Substance Use in the US, 2012)
" In 2012, about 2.9 million persons aged 12 or older used an illicit drug for the first time within the past 12 months; this averages to about 7,900 new users per day. This estimate was not significantly different from the number in 2011 (3.1 million). Over half of initiates (55.1 percent) were younger than age 18 when they first used, and 53.7 percent of new users were female. The 2012 average age at initiation among persons aged 12 to 49 was 18.7 years, which was similar to the 2011 estimate (18.1 years). See Section B.4.1 in Appendix B for a discussion of the effects of older adult initiates on estimates of mean age at first use.
" Of the estimated 2.9 million persons aged 12 or older in 2012 who used illicit drugs for the first time within the past 12 months, a majority reported that their first drug was marijuana (65.6 percent) (Figure 5.1). More than 1 in 4 initiated with nonmedical use of psychotherapeutics (26.0 percent, including 17.0 percent with pain relievers, 4.1 percent with tranquilizers, 3.6 percent with stimulants, and 1.3 percent with sedatives). A notable proportion reported inhalants (6.3 percent) as their first illicit drug, and a small proportion used hallucinogens (2.0 percent). All of the above 2012 percentages of first illicit drug use were similar to the corresponding percentages in 2011."Source:Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013, p. 52.
(Source of Gateway Effect) "The gateway effect, if it exists, has at least two potential and quite different sources (MacCoun, 1998). One interpretation is that it is an effect of the drug use itself (e.g., trying marijuana increases the taste for other drugs or leads users to believe that other substances are more pleasurable or less risky than previously supposed). A second interpretation stresses peer groups and social interactions. Acquiring and using marijuana regularly may lead to differentially associating with peers who have attitudes and behaviors that are prodrug generally, not only with respect to marijuana. One version of this is the possibility that those peers will include people who sell other drugs, reducing the difficulty of locating potential supplies. If the latter is the explanation, then legalization might reduce the likelihood of moving on to harder drugs compared to the current situation."Source:Kilmer, Beau; Caulkins, Jonathan P.; Pacula, Rosalie Liccardo; MacCoun, Robert J.; Reuter, Peter H., "Altered State? Assessing How Marijuana Legalization in California Could Influence Marijuana Consumption and Public Budgets" Drug Policy Research Center (Santa Monica, CA: RAND Corporation, 2010), p. 42.
(Cannabis and Progression to Other Drug Use) "While the findings of this study indicate that early cannabis use is associated with increased risks of progression to other illicit drug use and drug abuse/dependence, it is not possible to draw strong causal conclusions solely on the basis of the associations shown in this study."Source:Lynskey, Michael T., PhD, et al., "Escalation of Drug Use in Early-Onset Cannabis Users vs Co-twin Controls," Journal of the American Medical Association, Vol. 289 No. 4, January 22/29, 2003, p. 432.
(Teen Marijuana Use and Progression to Other Drugs) "Our results indicate a moderate relation between early teen marijuana use and young adult abuse of other illicit substances; however, this association fades from statistical significance with adjustments for stress and life-course variables. Likewise, our findings show that any causal influence of teen marijuana use on other illicit substance use is contingent upon employment status and is short-term, subsiding entirely by the age of 21. In light of these findings, we urge U.S. drug control policymakers to consider stress and life-course approaches in their pursuit of solutions to the 'drug problem.'"Source:Van Gundy, Karen and Rebellon, Cesar J., "Life-course Perspective on the “Gateway Hypothesis” Journal of Health and Social Behavior (Thousand Oaks, CA: American Sociological Association, September 2010), p. 244.
(Alcohol and Tobacco As Gateway Factors) "While covariates differed between equations, early regular use of tobacco and alcohol emerged as the 2 factors most consistently associated with later illicit drug use and abuse/dependence. While early regular alcohol use did not emerge as a significant independent predictor of alcohol dependence, this finding should be treated with considerable caution, as our study did not provide an optimal strategy for assessing the effects of early alcohol use."Source:Lynskey, Michael T., PhD, et al., "Escalation of Drug Use in Early-Onset Cannabis Users vs Co-twin Controls," Journal of the American Medical Association, Vol. 289 No. 4, January 22/29, 2003, p. 430.
(Other Associations Between Cannabis and Subsequent Drug Use) "Other mechanisms that might mediate a causal association between early cannabis use and subsequent drug use and drug abuse/dependence include the following:
"1. Initial experiences with cannabis, which are frequently rated as pleasurable, may encourage continued use of cannabis and also broader experimentation.
"2. Seemingly safe early experiences with cannabis may reduce the perceived risk of, and therefore barriers to, the use of other drugs. For example, as the vast majority of those who use cannabis do not experience any legal consequences of their use, such use may act to diminish the strength of legal sanctions against the use of all drugs.
"3. Alternatively, experience with and subsequent access to cannabis use may provide individuals with access to other drugs as they come into contact with drug dealers. This argument provided a strong impetus for the Netherlands to effectively decriminalize cannabis use in an attempt to separate cannabis from the hard drug market. This strategy may have been partially successful as rates of cocaine use among those who have used cannabis are lower in the Netherlands than in the United States."Source:Lynskey, Michael T., PhD, et al., "Escalation of Drug Use in Early-Onset Cannabis Users vs Co-twin Controls," Journal of the American Medical Association, Vol. 289 No. 4, January 22/29, 2003, p. 430.
(Little Evidence of Causal Gateway Effect) "After applying these methods, there is very little remaining evidence of any causal gateway effect. For example, even if soft/medium drugs (cannabis, amphetamines, LSD, magic mushrooms, amyl nitrite) could somehow be abolished completely, the true causal link with hard drugs (crack, heroin, methadone) is found to be very small. For the sort of reduction in soft drug use that might be achievable in practice, the predicted causal effect on the demand for hard drugs would be negligible. Although there is stronger evidence of a gateway between soft drugs and ecstasy/cocaine, it remains small for practical purposes. My interpretation of the results of this study is that true gateway effects are probably very small and that the association between soft and hard drugs found in survey data is largely the result of our inability to observe all the personal characteristics underlying individual drug use. From this viewpoint, the decision to reclassify cannabis seems unlikely to have damaging future consequences."Source:Pudney, Stephen, "Home Office Research Study 253: The road to ruin? Sequences of initiation into drug use and offending by young people in Britain" (London, England: Home Office Research, Development, and Statistics Directorate, December 2002), p. vi.
(Other Hypotheses for Sequence of Initiation into Drug Use) "The causal significance of this sequence of initiation into drug use remains controversial. The hypothesis that it represents a direct effect of cannabis use upon the use of the later drugs in the sequence is the least compelling. There is better support for two other hypotheses which are not mutually exclusive: that there is a selective recruitment into cannabis use of nonconforming adolescents who have a propensity to use other illicit drugs; and that once recruited to cannabis use, the social interaction with other drug using peers, and exposure to other drugs when purchasing cannabis on the black-market, increases the opportunity to use other illicit drugs"Source:Hall, W., Room, R. & Bondy, S., WHO Project on Health Implications of Cannabis Use: A Comparative Appraisal of the Health and Psychological Consequences of Alcohol, Cannabis, Nicotine and Opiate Use, August 28, 1995 (Geneva, Switzerland: World Health Organization, March 1998).
(Alcohol and Tobacco as Gateway Factors Among US Youth, 2012)
" In 2012, the rate of current illicit drug use among youths aged 12 to 17 who smoked cigarettes in the past month was approximately 8.5 times higher than the rate among those who did not smoke cigarettes in the past month (54.6 vs. 6.4 percent).
" In 2012, the rate of current illicit drug use was associated with the level of past month alcohol use. Among youths aged 12 to 17 who were heavy drinkers (i.e., consumed five or more drinks on the same occasion on each of 5 or more days in the past 30 days), 67.9 percent were current illicit drug users, which was higher than the rate among those who were not current alcohol users (5.2 percent). Additionally, among youths aged 12 to 17 who were binge but not heavy alcohol users (i.e., consumed five or more drinks on the same occasion on 1 to 4 days in the past 30 days), 42.1 percent were current illicit drug users.
" In 2012, the rate of current illicit drug use among youths aged 12 to 17 who both smoked cigarettes and drank alcohol in the past month was approximately 15 times higher than the rate among those who neither smoked cigarettes nor drank alcohol in the past month (61.1 vs. 4.0 percent). However, the 2012 rate of current illicit drug use among youths aged 12 to 17 who both smoked cigarettes and drank alcohol decreased from the 2011 rate of 68.7 percent."Source:Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013, pp. 28-29.
(Nonconformance with Substance Use Sequence of Stages) "The gateway hypothesis holds that abusable drugs occupy distinct ranks in a hierarchy as well as definite positions in a temporal sequence. Accordingly, substance use is theorized to progress through a sequence of stages, beginning with legal, socially acceptable compounds that are low in the hierarchy, followed by use of illegal 'soft' and later 'hard' drugs ranked higher in the hierarchy. One of the main findings of this study is that there is a high rate of nonconformance with this temporal order. In a neighborhood where there is high drug availability, youths who have low parental supervision are likely to regularly consume marijuana before alcohol and/or tobacco. Consumption of marijuana prior to use of licit drugs thus appears to be related to contextual factors rather than to any unique characteristics of the individual. Moreover, this reverse pattern is not rare; it was observed in over 20% of our sample."Source:Tarter, Ralph E., PhD, Vanyukov, Michael, PhD, Kirisci, Levent, PhD, Reynolds, Maureen, PhD, Clark, Duncan B., MD, PhD, "Predictors of Marijuana Use in Adolescents Before and After Licit Drug Use: Examination of the Gateway Hypothesis," American Journal of Psychiatry, Vol. 63, No. 12, December 2006, p. 2138.
(Screening Young People for "Gateway Violations" Unproductive) "Deviations from normative patterns of drug use initiation that involve the initiation of illicit drug use earlier than usual in the gateway pattern of initiation may carry small risks for dependence, but other factors seem to be more important in the development of drug dependence. Drug use and initiation are clearly nested within a social normative context, yet neither adherence nor deviation from this order signals highly elevated risks of drug problems in and of themselves, although some violations are predicted by pre-existing mental disorders that seem to be more powerful risk factors for subsequent substance dependence. Although a gateway violation might be a marker of such risk factors, their associations with gateway violations are relatively modest. In targeting intervention efforts, it would probably be more productive to screen directly for these factors (i.e. internalizing disorders, early-onset substance use) than to screen for gateway violations."Source:Degenhardt, L.; Chiu, W. T.; Conway, K.; Dierker, L.; Glantz, M., Kalaydjian, A.; Merikangas, K.; Sampson, N.; Swendsen, J.; and Kessler, R. C., "Does the ‘gateway’ matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication," Psychological Medicine (Cambridge, United Kingdom: Cambridge University Press, January 2009), p. 8.
(Behavioral Deviancy as Risk Factor for Illicit Drug Use) "The results of this study suggest that general behavioral deviancy and not specific risk factors accounts for illicit drug use. When illicit drug use occurs first, it is very likely due to the opportunity afforded by the neighborhood environment in context of low parental supervision. The probability and rate of development of a diagnosis of marijuana use disorder and alcohol use disorder were the same whether or not there was conformance with the gateway sequence. Evidence supporting 'causal linkages between stages,' as specified by the gateway hypothesis, was not obtained. Nor were specific risk factors identified that were related to consumption of each drug. Our results indicate that efforts to prevent marijuana use should utilize strategies directed at averting the development of the characteristics prodromal to the manifestation of behavior problems."Source:Tarter, Ralph E., PhD, Vanyukov, Michael, PhD, Kirisci, Levent, PhD, Reynolds, Maureen, PhD, Clark, Duncan B., MD, PhD, "Predictors of Marijuana Use in Adolescents Before and After Licit Drug Use: Examination of the Gateway Hypothesis," American Journal of Psychiatry, Vol. 63, No. 12, December 2006, p. 2139.
(Specific Risk Factors do not Predict Future Drug Use) "Our key findings were that 1) there are no unique factors distinguishing the gateway sequence and the reverse sequence that is, the sequence is opportunistic; 2) the gateway sequence and the reverse sequence have the same prognostic accuracy; and 3) a sizable proportion of substance users begin regular consumption with an illicit drug. These results, considered in the aggregate, indicate that the gateway sequence is not an invariant pathway and, when manifest, is not related to specific risk factors and does not have prognostic utility. The results of this study as well as other studies demonstrate that abusable drugs occupy neither a specific place in a hierarchy nor a discrete position in a temporal sequence. These latter presumptions of the gateway hypothesis constitute what Whitehead referred to as the 'fallacy of misplaced connectedness,' namely, asserting 'assumptions about categories that do not correspond with the empirical world.'"Source:Tarter, Ralph E., PhD, Vanyukov, Michael, PhD, Kirisci, Levent, PhD, Reynolds, Maureen, PhD, Clark, Duncan B., MD, PhD, "Predictors of Marijuana Use in Adolescents Before and After Licit Drug Use: Examination of the Gateway Hypothesis," American Journal of Psychiatry, Vol. 63, No. 12, December 2006, p. 2139.
(Evaluating Gateway Theory Using Cross-National Data) "The present paper examined the extent and ordering of licit and illicit drug use across 17 disparate countries worldwide. This comparison, using surveys conducted with representative samples of the general population in these countries, and assessment involving comparable instruments, allowed for the first assessment of the extent to which initiation of drug use follows a consistent pattern across countries. Previous studies, concentrated in high income countries with relatively high levels of cannabis use, have documented: a common temporal ordering of drug initiation; an increased risk of initiating use of a drug later in the sequence once having initiated an earlier one; and the persistence of the association following controlling for possibly confounding factors (Kandel et al., 2006).
"The present study supported the existence of other factors influencing the ordering and progression of drug use because 1) other illicit drug use was more prevalent than cannabis use in some countries, e.g. Japan; 2) the association between initiation of 'gateway' drugs (i.e. alcohol/tobacco and cannabis), and subsequent other illicit drug use differed across countries, in some instances according to background prevalence of use of these gateway drugs; and 3) cross-country differences in drug use prevalence corresponded to differences in the prevalence of gateway violations.
"Higher levels of other illicit drug use compared to cannabis use were documented in Japan, where exposure to cannabis and tobacco/alcohol was less common. In this case, a lack of exposure and/or access to substances earlier in the normative sequence did not correspond to reductions in overall levels of other illicit drug use. This finding is contrary to the assumption that initiation reflects a universally ordered sequence in which rates of drug use later in the sequence must necessarily be lower than those earlier in the sequence (Kandel, 2002). This has not previously been reported as research has been traditionally conducted in countries where use of tobacco, alcohol and cannabis is relatively common."Source:Louisa Degenhardt, et al., "Evaluating the drug use 'gateway' theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys," Drug and Alcohol Dependence, 2010 April 1; 108(1-2): 84-97, doi:10.1016/j.drugalcdep.2009.12.001.
(Medical Cannabis Patients and Other Drug Use) "Analysis of the demographic and social characteristics of a large sample of applicants seeking approval to use marijuana medically in California supports an interpretation of long term non problematic use by many who had first tried it as adolescents, and then either continued to use it or later resumed its use as adults. In general, they have used it at modest levels and in consistent patterns which anecdotally-often assisted their educational achievement, employment performance, and establishment of a more stable life-style. These data suggest that rather than acting as a gateway to other drugs, (which many had also tried), cannabis has been exerting a beneficial influence on most."Source:Thomas J O'Connell and Ché B Bou-Matar, "Long term marijuana users seeking medical cannabis in California (2001–2007): demographics, social characteristics, patterns of cannabis and other drug use of 4117 applicants," Harm Reduction Journal, (November 2007).
(Marijuana Use as a Gateway to Other Drug Use) "There is no conclusive evidence that the drug effects of marijuana are causally linked to the subsequent abuse of other illicit drugs."Source:Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 6.
(Patterns in Progression of Drug Use) "Patterns in progression of drug use from adolescence to adulthood are strikingly regular. Because it is the most widely used illicit drug, marijuana is predictably the first illicit drug most people encounter. Not surprisingly, most users of other illicit drugs have used marijuana first. In fact, most drug users begin with alcohol and nicotine before marijuana, usually before they are of legal age."Source:Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 99.