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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
Open accessAbstract
Background It is unclear whether the normative sequence of drug use initiation, beginning with tobacco and alcohol, progressing to cannabis and then other illicit drugs, is due to causal effects of specific earlier drug use promoting progression, or to influences of other variables such as drug availability and attitudes. One way to investigate this is to see whether risk of later drug use in the sequence, conditional on use of drugs earlier in the sequence, changes according to time-space variation in use prevalence. We compared patterns and order of initiation of alcohol, tobacco, cannabis, and other illicit drug use across 17 countries with a wide range of drug use prevalence. Method Analyses used data from World Health Organization (WHO) World Mental Health (WMH) Surveys, a series of parallel community epidemiological surveys using the same instruments and field procedures carried out in 17 countries throughout the world. Results Initiation of "gateway" substances (i.e. alcohol, tobacco and cannabis) was differentially associated with subsequent onset of other illicit drug use based on background prevalence of gateway substance use. Cross-country differences in substance use prevalence also corresponded to differences in the likelihood of individuals reporting a non-normative sequence of substance initiation. Conclusion These results suggest the "gateway" pattern at least partially reflects unmeasured common causes rather than causal effects of specific drugs on subsequent use of others. This implies that successful efforts to prevent use of specific "gateway" drugs may not in themselves lead to major reductions in the use of later drugs.
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“Although epidemiological data suggest that tobacco acts as a ‘gateway’ to subsequent substance abuse (Kandel et al. 1992; Lai et al. 2000; Degenhardt et al. 2010), it is not clear from human studies whether this reflects social influences or a drug effect (Lindsay & Rainey, 1997; Anthony, 2012).”
From Nicotine and the adolescent brain (2015) · cites this paper as Degenhardt et al. 2010
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Metadata
- Authors
- Degenhardt, L., Dierker, L., Chiu, W. T., Medina-Mora, M. E., Neumark, Y., Sampson, N., Alonso, J., Angermeyer, M., Anthony, J. C., Bruffaerts, R., de Girolamo, G., de Graaf, R., Gureje, O., Karam, A. N., Kostyuchenko, S., Lee, S., Lépine, J.-P., Levinson, D., Nakamura, Y., Posada-Villa, J., Stein, D., Wells, J. E., & Kessler, R. C.
- Affiliations
- UNSW Sydney (AU)
- Wesleyan University (US)
- Harvard University (US)
- Hebrew University of Jerusalem (IL)
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (ES)
- Michigan State University (US)
- Universitair Ziekenhuis Leuven (BE)
- Regione Emilia-Romagna (IT)
- University College Hospital, Ibadan (NG)
- Chinese University of Hong Kong (HK)
- Hôpital Fernand-Widal (FR)
- Israel Ministry of Health (IL)
- Jichi Medical University (JP)
- University of Cape Town (ZA)
- University of Otago (NZ)
- Corresponding author
- Degenhardt, Louisa
- ORCID
- Venue
- Drug and Alcohol Dependence
- Publisher
- Elsevier BV
- Published
- 2010-04
- Volume
- 108
- Issue
- 1-2
- Pages
- 84-97
- ISSN
- 0376-8716 (ISSN-L)
- PMC
- PMC2835832
- OpenAlex
- W2167374867
- Cited by
- 271
- References
- 39
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 7 · 2023: 13 · 2022: 7 · 2021: 14 · 2020: 24 · 2019: 14 · 2018: 17 · 2017: 19 · 2016: 33 · 2015: 29 · 2014: 30 · 2013: 17 · 2012: 18
- FWCI
- 12.37
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Drug and Alcohol Dependence (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- RECERCAT (Consorci de Serveis Universitaris de Catalunya) (acceptedVersion, other-oa)
- Repositori digital de la UPF (Universitat Pompeu Fabra) (submittedVersion)
- Funders
- National Institutes of Health (5r13mh066849-04, 5r01mh069864-04, 5r01mh070884-05)
- National Institute of Mental Health (R13-MH-066849, R0 1-MH61905, R01‐MH070884, U01-MH-60220, R01MH061905, R01MH059575, U13MH066849, U01MH060220, R01‐MH069864)
- National Institute on Drug Abuse (DA010075, K01DA015454, K05DA015799, R01DA016558, DA024260, T32DA021129, DA15454, P50DA010075, R21DA024260)
- Fogarty International Center (R01-TW006481, R03TW006481)
- Topics
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Youth, Drugs, and Violence
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
- Keywords
- gateway theory, drug initiation, alcohol consumption, tobacco use, cannabis use, illicit drug use, cross-national comparison, substance use prevalence, substance use prevention
- MeSH terms
- Adolescent, Adult, Age Factors, Aged, Alcoholism, Mental Disorders, Female, Humans, Interview, Psychological, Male, Marijuana Smoking, Middle Aged, Smoking, World Health Organization, Cohort Studies, Databases, Factual, Diagnosis, Dual (Psychiatry), Disease Progression, Substance-Related Disorders, Young Adult
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