A developmental sequence of involvement in drugs is one of the best
replicated findings in the epidemiology of drug use. Regular sequences and
stages of progression in which the use of alcohol and cigarettes precedes
the use of marijuana (cannabis), and, in turn, the use of marijuana precedes
the use of other illicit drugs, has been observed in the United States as
well as in other western societies.1 Very few
individuals who have tried cocaine and heroin have not already used marijuana;
the majority have previously used alcohol or tobacco. Such behavioral regularities
are subsumed under the "gateway hypothesis." The gateway hypothesis implies
3 interrelated propositions about sequencing, association of initiation, and
that there is a fixed relationship between 2 substances, such that one substance
is regularly initiated before the other. Association implies
that initiation of one substance increases the likelihood of initiation of
the second substance. Causation implies that use
of the first substance actually causes use of the second substance. Causation,
a controversial proposition, is the one most widely invoked in policy debates
and is the proposition addressed in the article by Lynskey et al in this issue
of THE JOURNAL.2
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