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

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

doi:10.1016/j.drugalcdep.2009.12.001

« Previous Next »Drug and Alcohol Dependence
Volume 108, Issue 1 , Pages 84-97, 1 April 2010

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
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
- Corresponding author. Tel.: +61 2 9385 0230; fax: +61 2 9385 0222.
Lisa Dierker
- The Methodology Center, Penn State University, PA, United States
- Psychology Department, Wesleyan University, 207 High Street, Middletown, CT, United States
Wai Tat Chiu
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, United States
Maria Elena Medina-Mora
- Department of Epidemiology, National Institute of Psychiatry, Calzada Mexico Xochimilco, No. 101, Col. San Lorenzo Huipulco, Tlalpan, Mexico City, DF 14370, Mexico
Yehuda Neumark
- Braun School of Public Health and Community Medicine, Hebrew University-Hadassah, PO Box 12272, Jerusalem, Israel
Nancy Sampson
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, United States
Jordi Alonso
- Health Services Research Unit, Institut Municipal d’Investigacio Medica (IMIM), CIBER en Epidemiología y Salud Pública (CIBERESP), Dr. Aiguader, 88, Barcelona 08003, Spain
Matthias Angermeyer
- Center for Public Health, Untere Zeile 13, A-3482, Gösing am Wagram, Austria
James C. Anthony
- Department of Epidemiology, Michigan State University, B601 West Fee Hall, East Lansing, MI 48823, United States
Ronny Bruffaerts
- Department of Neurosciences and Psychiatry, University Hospital Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium
Giovanni de Girolamo
- Regional Health Care Agency, Emilia-Romanga Region, Via Aldo Moro 21, Bologna 40127, Italy
Ron de Graaf
- Netherlands Institute of Mental Health and Addiction, Da Costakade 45, Utrecht 3521 VS, The Netherlands
Oye Gureje
- Department of Psychiatry, University College Hospital, Ibadan PMB 5116, Nigeria
Aimee N. Karam
- St. George Hospital University Medical Center, Balamand University, Faculty of Medicine, Institute for Development, Research, Advocacy & Applied Care (IDRAAC), 166227 Achrafieh, Beirut 1100 2110, Lebanon
Stanislav Kostyuchenko
- Ukrainian Psychiatric Association, 103a Frunze Street, Kiev 04080, Ukraine
Sing Lee
- Department of Psychiatry, The Chinese University of Hong Kong, Flat 7A, Block E, Staff Quarters, Shatin, HKSAR, People's Republic of China
Jean-Pierre Lépine
- Hospital Fernand Widal, 200 rue du Faubourg Saint Denis, Paris 75010, France
Daphna Levinson
- Director Research & Planning, Ministry of Health, Mental Health Services, 2 Ben Tabal St., Jerusalem 91010, Israel
Yosikazu Nakamura
- Department of Public Health, Jichi Medical School, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken 329-0498, Japan
Jose Posada-Villa
- Colegio Mayor de Cundinamarca University, U. Javerina, Cra. 7 No. 119-14 Cons 511, Bogata, Colombia
Dan Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7505, South Africa
J. Elisabeth Wells
- Department of Public Health and General Practice, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand
Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, United States

Received 21 November 2008; received in revised form 1 December 2009; accepted 2 December 2009.

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: Tobacco, Alcohol, Illicit drugs, Gateway, WHO World Mental Health Surveys