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. 2010 Apr 1;108(1-2):84-97.
doi: 10.1016/j.drugalcdep.2009.12.001. Epub 2010 Jan 8.

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

Louisa Degenhardt  1 , Lisa Dierker, Wai Tat Chiu, Maria Elena Medina-Mora, Yehuda Neumark, Nancy Sampson, Jordi Alonso, Matthias Angermeyer, James C Anthony, Ronny Bruffaerts, Giovanni de Girolamo, Ron de Graaf, Oye Gureje, Aimee N Karam, Stanislav Kostyuchenko, Sing Lee, Jean-Pierre Lépine, Daphna Levinson, Yosikazu Nakamura, Jose Posada-Villa, Dan Stein, J Elisabeth Wells, Ronald C Kessler
Affiliations

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

Louisa Degenhardt et al. Drug Alcohol Depend. .

Abstract

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.

Keywords: WHO World Mental Health Surveys; alcohol; gateway; illicit drugs; tobacco.

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