The Journal of Primary Prevention, Vol. 12, No. 4, 1992
The Prevention of Drug Use Among Youth: Implications of "Legalization" Richard R. Clayton, Ph.D. 1 and Carl G. Leukefeld, D.S.W. z
This paper examines what would happen if marijuana were legalized in the United States. KEY WORDS: Gateway drugs; legalization; youth.
INTRODUCTION The primary purpose of this paper is to examine the implications of "legalizing" marijuana on primary prevention efforts in the United States. The goals of "primary" prevention are to increase the percentage of young people who choose to "never" use drugs and, for those who do choose to use drugs, to delay the onset of use. Further, the goal is to reduce the percentage who progress to more intensive and extensive use within drug classes and to decrease the percentage who progress across drug classes. We have chosen the "gateway" drugs phenomenon to set the context for what would happen if marijuana were legalized in the United States. We have also chosen to focus on gateway drugs because there is so much misinformation about the process by which people become increasingly more involved with drugs. Therefore, the first section of this paper will review what is known about the "gateway" drugs nicotine (cigarettes is the proxy here), alcohol, and marijuana. 1Richard R. Clayton, Ph.D., is Professor of Sociology and Psychiatry, and Scientific Director, University of Kentucky. Address correspondence and reprint requests to: Center for Prevention Research, University of Kentucky, 147 Washington Avenue, Lexington, KY 40506-0402. 2Carl G. Leukefeld, D.S.W., is Professor of Psychiatry and Director, Multidisciplinary Center on Alcohol and Drug Abuse, University of Kentucky. 289 © 1992Human Sciences
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THE "GATEWAY" DRUGS: "DEVELOPMENTAL" STAGES OF DRUG USE
Health educators, other teachers, and parents are all participants in systems built on "developmental" assumptions. For many of us, Piaget, Erickson, Kohlberg, and Havighurst are familiar names--the philosophical founders of what we do each and every work day. We believe that learning is both deductive and inductive, that what is taught and learned in one grade, or at one age, is carried forward and expanded, enlarged, enhanced, and reinforced in subsequent grades and ages. Over time we have learned that behavior, like cognitive functioning, occurs in developmental stages. In 1975 Denise Kandel, a sociologist at Columbia University, first identified the "developmental stages" of drug use. She observed, and correctly, that there is a distinct pattern or stages of initiation into the use of drugs. These stages are: 1, No use of any drugs 2. Use of beer or wine 3. Use of cigarettes and/or hard liquor 4. Use of marijuana 5. Use of other illicit drugs such as heroin and cocaine It is important to note that not all people go through these stages. Some people never begin using drugs--they stay at stage 1. Some enter stages 2 and 3, but never go on to using "illicit" drugs. Over the past 25 or so years, a substantial percentage of Americans have experimented with marijuana. Many who have tried marijuana have used it a few times and stopped, while others have continued to use it and perhaps have become even heavier users. However, some have gone on to use cocaine and/or heroin. Thus, one conclusion to be reached from Kandel's developmental stages approach is that onset of drug use is very patterned. Very rarely does someone use cocaine without previously using drugs in the prior stages. In fact, Kandet and others (Yamaguchi and Kandel, 1984a, 1984b; O'Donnell and Clayton, 1982; Henningfield, Clayton, and Pollin, 1990) have shown that marijuana use is essentially a "necessary" condition for the occurrence of cocaine use. Almost no one uses cocaine who has not previously used marijuana. This may not always have been true, but it is certainly true now and has been the case for at least the past 25 years. This does not mean there are no exceptions. There are certainly some who have used cocaine and not previously used marijuana or other gateway drugs, but they are exceedingly rare. The overwhelming majority of those who make it to the latter developmental stages have progressed through the prior stages.
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A second conclusion is that movement to more serious stages of drug use is probabilistic. The more extensive, the more intensive, the longer one uses drugs such as marijuana, the more likely it is that a person will begin to use drugs such as cocaine and heroin. The process here is not one of certainty, but rather one of probability. Not everyone who uses marijuana, even extensively, uses cocaine. In subsequent work, Kandel, Davies, and Raveis (1985) have suggested that there may be another stage between use of marijuana and use of other illicit drugs (i.e., use of prescription drugs such as tranquilizers, sedatives, stimulants, or analgesics). This stage, if it exists, is probably more likely to occur for females than males because of the differential prevalence by gender of benzodiazepine use. John Donovan and Richard Jessor, psychologists at the University of Colorado, have suggested that "problem drinking" may occur as a stage between use of marijuana and use of other illicit drugs (1983). This illustrates an important aspect of the developmental stages approach to drug use. When someone reaches stage 4, marijuana use, they continue and often have increased their use of those drugs at earlier stages: alcoholic beverages and cigarettes.
NUMBER OF YOUTH WHO USE DRUGS The data shown in Table 1 are from the 1985 National Household Survey on Drug Abuse, the 8th survey in this particular series of studies. The 12-17 year olds were chosen to be representative of all young people those ages who live in households in the continental United States. They were personally interviewed in a private setting within their homes and were guaranteed the confidentiality of their responses. Other analyses not presented here suggest that the overwhelming majority of these students provided honest answers to the questions.
USE OF MARIJUANA AND COCAINE The first and most obvious conclusion from these data is that these youth, representative of the "general" population, have not been insulated from illicit drugs. Close to 1 in 4 of all 12 to 17 year olds have tried marijuana. Involvement with marijuana is clearly a developmental phenomenon with 5.8% of the 12 to 13 year olds having tried it compared to 23.4% of the 14 to 15 year olds and 40.4% of the 16 to 17 year olds. These are very large jumps in lifetime prevalence indicating that the 9th, 10th, and l l t h
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Table I. Percentage of 12 to 17 Year Olds Reporting Lifetime, Past Year, Past Month Use of Cigarettes, Alcohol, Marijuana, Cocaine: National Household Survey on Drug Abuse 1985
Drugs and Age Groups
Lifetime
Past Year
Past Month
Cigarettes All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
45.2% 27.8% 47.1% 59.4%
25.8% 13.8% 26.0% 36.8%
15.3% 5.9% 14.3% 25.3%
Alcohol All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
55.5% 27.5% 61.0 75.8%
51.7% 24.2% 57.0% 71.8%
31.0% 10.8% 34.7% 45.9%
Marijuana All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
23.6 5.8% 23.4% 40.4%
19.7% 4.8% 20.4% 33.1%
12.0% 3.5% 11.0% 21.0%
Cocaine All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
4.9% 0.5% 4.6% 9.4%
4.0% 0.5% 4.1% 7.4%
1.5% a 1.0% 3.2%
aLess than one-half of one percent.
grades are particularly important, a time when youth are quite vulnerable to initiation into marijuana use. It is also important to note that the majority of 16 to 17 year olds have not tried marijuana. The second conclusion is that use in the month preceding the interview was not rare. Slightly over 1 in 5 of 16 to 17 year olds used marijuana in the prior 30 days as did slightly over 1 in 10 of 14 to 15 year olds. These facts suggest that any and all prevention efforts directed at youth face formidable challenges. The rates are obviously much lower for cocaine, but still illustrate the age-graded developmental patterns of initiation into this very dangerous drug. In data not shown here, an even more serious pattern of cocaine use emerged. When the sample was limited to just those who had ever used cocaine, 44% of 12 to 17 year olds reported having "smoked" or "freebased" cocaine at some time in their life. Among adults 18-25, 26-34, or 35 years old and older who had ever used cocaine, approximately 20% had smoked or freebased it (NIDA, 1988).
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These are dramatic differences. They are startling because the quickest way to get a drug to the brain is by smoking it. Within seven seconds after inhaling the smoke or vapors from cocaine receptor sites in the brain are detecting the drug. While the percentage of youth reporting having used cocaine is "relatively" low, any level of use of this dangerous drug is too high. If, in addition, the way they are using the drug is one of the more dangerous "routes of administration," there is greater cause for concern.
USE OF ALCOHOL AND CIGARETTES In every state, alcohol and cigarettes are "illicit" drugs for persons under the age of either 18 or 21. While alcohol use in particular is woven into many of our rituals and everyday events of adult life, these drugs should not be legally available to our youth. The data in Table 1 show just how widely the law is violated with regard to alcohol by young people in the United States. Over 1 in 10 youth 12 to 13 years old had used alcohol in the month preceding the interview while the figures were over 1 in 3 for 14 to 15 year olds and close to 1 in 2 for 16 to 17 year olds. The magnitude of these figures illustrate why alcohol is implicated in many of the fatalities among youth and why so many youth with seemingly "unlimited" potential fail to achieve. The 1988 report from the Surgeon General on Smoking and Health provided reams of evidence confirming what virtually all long term smokers know all too well - nicotine is a very addicting drug. The Surgeon General's report indicates that nicotine may be as addicting as heroin or cocaine. In graphic terms, a cigarette is just as much a drug delivery system as a crack pipe or a hypodermic needle. The data in Table 1 show that over 1 in 4 youth 12 to 13 years old have tried cigarettes and 5.9% had smoked cigarettes during the month prior to the interview. The rates are higher the older the student such that 1 in 4 (25.3%) 16 to 17 year olds reported smoking in the previous month.
THE CONCEPT OF CAUSALITY If you were asked whether smoking "causes" lung cancer or cardiovascular disease, your answer would probably be: "Of course, everybody knows that!" The Surgeon General used criteria commonly accepted by scientists in many disciplines to establish these "causal" relationships. The first and perhaps most important criterion of causality is correlation. How-
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ever, just because two things are correlated does not mean they are "causally" related. For example, even though the heat of the sidewalks in New York City is statistically correlated with the homicide rate, we wouldn't claim the temperature is the "cause" of the murder rate. Correlation as a basis for claiming causality must be statistical AND logical. In addition to the relationship being "logical," at least two other criteria of causality must be satisfied: (a) the presumed "cause" must occur prior to the presumed "effect," and (b) alternative explanations for the relationship between the presumed cause and the presumed effect must be eliminated (i.e., testing for spuriousness). For example, before one can claim that smoking causes lung cancer, it is necessary to eliminate the possibility that genetic and other environmental factors were responsible for the statistical relationship (i.e., correlation) between smoking and lung cancer.
GATEWAY DRUGS AND CORRELATION There are two very important facts related to the gateway drugs phenomenon. First, the stages of initiation into use of various drugs (i.e., the sequencing of onset) is consistent across many different kinds of groups. In the overwhelming majority of cases, cigarette and alcohol use precede marijuana use which almost invariably precedes use of other drugs such as cocaine. Therefore, temporal order of onset is not an issue for debate. The data in Table 2 show the degree to which use of these gateway drugs are correlated. The data are all for "past month" use of the drugs. As the data show clearly, those who have used the gateway drugs--marijuana, alcohol, or cigarettesmduring the past month are considerably more likely than those who have not used them to report using other drugs. For example, 10.5% of the past month users of marijuana report past month use of cocaine compared to less than one-half of one percent of those who had not used marijuana in the past month. However, from the perspective of a teacher or school administrator, this information is difficult to translate into something practical. People often go to great lengths to conceal their marijuana and cocaine use. Alcohol use is also clearly related to use of other drugs. For example, 32.3% of past month users of alcohol report past month use of marijuana compared to 2.8% of those who had not had anything to drink in the past month. This information is again interesting but may have limited practical utility. Most underage students restrict their drinking to nighttime and/or weekends.
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THE IMPORTANCE OF CIGARETI?ES AS A GATEWAY DRUG
However, the data in Table 2 concerning cigarette use and use of other drugs provide the same story but with different practical implications. The size of difference between two percentages is an indication of the degree of correlation. This is called a "delta" value. The delta value or correlation between cigarette smoking and marijuana use is strong: 47.7% compared to 5.5%. To make this more graphic, consider the following illustration. A representative sample of 100 students 12-17 years old is standing on the 50 yard line in the football stadium. When you ask those who have smoked one or more cigarettes during the past month to set forward, 15 will do so. If the entire group, all 100, were asked to raise their hands if they smoked any marijuana during the previous 30 days, 7 of the 15 cigarette smokers would raise their hands while only 5 of the 85 nonsmokers would do so. Does this mean that cigarette smoking is "causally" related to marijuana use? This question can't be answered definitively without applying the other statistical and logical criteria used in testing for causality. However, we often act or react in our professional and personal lives according to observed correlations without solid and irrefutable evidence that two phenomena are "causally" related. We do this as parents when our children get involved with someone we consider to be a potentially bad influence. We do the same thing with young people in our classrooms. Shouldn't we do the same with this information on smoking and other drug use? If we are serious about drug abuse prevention and intervention, the most effective predictor o f who is using marijuana may be who is using cigarettes. One could predict with a fair degree of accuracy that almost one-half of students who are current cigarette smokers are also current marijuana users. We don't need to have a self-esteem score or some measure of personality to know who is at high risk for using "illegal" drugs; why not do like the toucan bird on the cereal commercial--"just follow your nose." Cigarette smoking is a visible behavior not usually concealed by students. Smokers can be seen on almost any campus before and after school. In fact, even a blind person could find the smoking area and spot the smokers in the halls using his or her sense of smell.
THE IMPLICATIONS OF A LEGALIZATION POLICY FOR PRIMARY PREVENTION
We were asked to review the effects marijuana legalization would have on drug abuse prevention efforts in the United Sates. We believe le-
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Table 2, Past Month Use of Cigarettes, Alcohol, and Marijuana and Past Month Use of Other Drugs Among 12 to 17 Year Olds: National Household Survey on Drug Abuse 1985
Cigarettes Past month use of Cigarettes Alcohol Marijuana Pillsa Cocaine
No (84.7%)
Yes (15.3%)
23.3% 5.5% 1.4% b
73.5% 47.7% 12.4% 8.2%
Alcohol
Marijuana
No (69.0%)
Yes (31.0%)
No (88.0%)
Yes (12.0%)
5.9%
36.4%
9.1% 23.9%
61.0% 83.8%
2.8% 0.7% b
32.3% 8.3% 4.7%
1.3% b
15.8% 10.5%
apills refers to nonmedical use of stimulants, sedatives, tranquilizers, or analgesics. bLess than one-half of one percent.
galization of marijuana in the U.S. is extremely unlikely by the federal government. However, in the sections below we make a serious attempt to examine the basic arguments offered for adopting legalization as a policy and offer arguments against this policy because of the potential impacts on efforts to "prevent" drug use. Finally, we will offer an alternative practical, and policy driven, approach to the problem of drug use among youth in the United States. One thing should be clear from the outset: We believe endorsement of a national policy of legalization is antithetical to preventing drug use.
BACKGROUND: FEDERAL DRUG POLICIES
Federal drug policies are usually discussed as SUPPLY REDUCTION and DEMAND REDUCTION. These two approaches are primarily relevant for current "illicit" drugs such as marijuana, heroin, cocaine, etc. These drugs constitute the focus of legalization discussions, and most of our attention in this paper is focused on these drugs; particularly marijuana. It should be noted that several states and communities have "legalized" the personal use of small amounts of marijuana, but none have done this for adolescents. There are policy approaches to other drugs, such as nicotine and alcohol, which are most appropriately classified as REGULATED. Products containing nicotine and alcohol are legal to produce, although the federal government regulates the production and marketing (i.e., supply) of tobacco through a price support and taxation system. Advertising and promoting to-
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bacco products is monitored and regulated by the federal government: a form of demand reduction. Laws and regulations at the federal, state, and local level attempt to regulate who may purchase products containing nicotine, where they may purchase them, and where these products may be consumed. With regard to alcohol, there are a number of regulatory policies concerning minimum age to purchase, types of alcoholic beverage products that may be purchased in specified circumstances, when these commodities may be sold, and consequences for persons who provide alcoholic beverages to guests/customers. In addition, products containing alcoholic beverages are taxed. Products containing nicotine and alcohol also contain specified warning labels. A fourth approach to drug policies involves REGULATION BY CONTROL. Here we refer to psychotherapeutic drugs such as the benzodiazepines and narcotic analgesics; drugs that may only be obtained legally via a prescription from a registered health care professional and prepared and distributed by a registered pharmacist. There are also drugs dispensed over-the-counter as pain killing agents which are regulated primarily in terms of required labeling. Drugs like caffeine are even used as marketing devices, caffeinated versus de-caffeinated products.
LEGALIZATION: WHAT'S IN A NAME? Different "labels" have been assigned to what is now called "legalization." During the Nixon administration, the National Commission on Marihuana and Other Drug Abuse endorsed a policy they called "partial prohibition" that would allow for regulated production and distribution of marijuana. That term was to some extent replaced by "decriminalization" which grew from the concern that many youth could be forever classified as drug abusers if prosecuted under laws which prohibited possession of even small amounts of marijuana. During the late 1970s and early 1980s, laws were changed in 11 states to classify possession of up to a certain amount of marijuana (the definition of "small" amount for personal use varied) as a "civil" rather than a "criminal" violation. One of the expressed goals of this policy change was a reduction in the number of criminal court cases being tried. At the time these "experiments" in drug use public policies were being implemented, some expected rapid diffusion of "decriminalization" into the remaining states. However, diffusion did not occur. In fact, no states have decriminalized marijuana since 1978. In this paper we focus on a policy of legalization and argue that such a policy is short sighted and illogical for the youth of our nation.
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LEGALIZATION: FLAWED ASSUMPTIONS 1. Current policies of prohibition have failed. The argument by the proponents of legalization that current policies have failed is usually based on two things. First, those who want to legalize are strongly opposed, in principle, to the use of criminal justice sanctions for so-called "victimless" crimes such as drug use. However, those who oppose legalization argue that drug use is not a victimless crime; the user, his or her family, and the society at large suffer major social and economic costs because of the user. Second, those who want to legalize drugs claim high prevalence use rates indicate widespread law violations which proves the lack of deterrence. However, there is clear indication from various general population surveys that most drug use rates are going down and have been since the late 1970s and early 1980s. In fact, Johnston, Bachman, and O'Malley (1990) indicate that the percentage of high school seniors who smoke marijuana daily is now less than 3%, down from its peak in 1979 of 11%, and even lower than it was in 1975 when this study was first conducted. The rates of cocaine use among high school seniors was also significantly lower in 1989 than it was in 1988 which continues a trend downward. Data from the 1988 National Household Survey on Drug Abuse (see NIDA, 1990) indicate significant decreases in most drug use. In addition, there has been a recent significant decline in cocaine as an identified drug in visits to emergency rooms. If current policies have failed, prevalence trends would be at least stable or increasing in order to justify a change in policy. Why would a society change the entire thrust of its drug policy orientation when the data consistently indicate "progress" in the desired direction of less among adolescents and others. 2. The American public is opposed to current policies and would prefer legalization to prohibition. The use of alcoholic beverages is very high among adults in this society; over three-fourths report some consumption of alcohol in the past 30 days. For them, alcohol use is "illegal." Wagenaar and Streff (1990), report results from a study of a representative sample of 760 Michigan adults. They found that even 74% of those who drank alcoholic beverages more than once a week were in favor of increasing excise taxes on alcohol and earmarking these funds to combat drinking driving. With the exception of frequent episodic heavy drinkers, large majorities favor prohibiting concurrent sales of alcoholic beverages and motor fuels. Two-thirds of the respondents favored immediate 90 day suspension of drivers' licenses upon arrest for driving over the legal limit. These are tough positions to be taken
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for a drug that is assumed to be woven into every aspect of American life. If this study is at all representative then why would anyone expect the positions toward currently illegal drugs to be changed. In fact, there is solid evidence from public opinion polls that attitudes toward legalization of marijuana have become less tolerant; not more tolerant (see Inciardi and McBride, 1989). To our knowledge, no credible data exist which suggest that the American public is in favor of legalizing marijuana or any other drug currently considered illicit.
AN ALTERNATIVE POLICY APPROACH: GET TOUGH ON THE LEGAL DRUGS We are always amazed and more than a little perplexed by those who argue for "legalization" of the currently illicit drugs. Their principal argument for legalization is that current government policies and programs have failed miserably. What is needed, they argue, is "regulation" of all drugs (i.e., control of the production, distribution, and revenue resulting from the sale of these drugs). Who will "regulate" these drugs? The answer is simple: the same government with new bureaucracies added for this purpose. But wait a minute. Isn't this the same government that they believe has failed with its current policies. Isn't this the same government that is supposed to regulate the distribution of the legal drug alcohol. According to the latest Monitoring the Future survey of high school seniors, 37% of all high school seniors report having had five or more drinks in a row on at least one occasion in the past two weeks. If we are not successfully regulating the distribution of alcohol, how can these critics of the current policy and its implementation, argue to add more drugs for governmental regulation? If our current efforts to curb drug use are not uniformly successful, legalization is not the only viable option. We could "get tougher on the legal drugs," particularly with regard to adolescent use.
IF WE ARE REALLY SERIOUS ABOUT DRUG PREVENTION If we really are serious about drug prevention in the United States, legalization is clearly not an answer. In fact, it is 180 degrees opposite. We already have at least two drugs, alcohol and nicotine, that are "legal" for adults which have major impacts on morbidity and mortality in the U.S. Norms about the nicotine use are changing in the desired direction. According to Warner (1989), there are 50 million instead of 91 million current
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smokers, because of consistent and strong anti-smoking efforts since 1964. As previously noted in the research conducted by Wagenaar and Streff (1990), it could be suggested that more stringent alcohol control policies and more strict sanctions against those who drink and drive are endorsed by a sizable majority of the American public. Given the social and economic costs attributable to alcohol and tobacco products, how could anyone argue persuasively to add another drug such as marijuana to that list, especially younger persons? However, it is also true that current procedures for limiting adolescent access to alcohol and tobacco products are not as effective as they might be. What can and could be done about these drugs? Several important considerations are discussed below. First, efforts at school based prevention interventions must be increased. A number of studies have demonstrated that it is possible to influence decisions to use or not use, or to continue or not continue to use cigarettes (see Flay et al., 1989; Pentz et al., 1990). However, these efforts are not sufficient to reduce the overall incidence and prevalence of cigarette use among youth. Efforts must also be made to alter the environment and norms concerning use of alcoholic beverages and tobacco products by adolescents. Second, availability is a major factor in the use of all types of drugs. For example, some communities have banned cigarette vending machines. This limits the number of outlets. This means that a young person who wants to purchase cigarettes must buy them from a person responsible for limiting access. Third, one of the problems with the so-called legal drugs is that they can be advertised. The tobacco industry spends close to $3 billion a year to get market share and brand loyalty. There are many who believe the real purpose of this advertising is to replace those who quit because of choice or by death. It is time to seriously consider greater restrictions on all advertising of these products. One strategy would be to progressively reduce the amount of advertising costs that can be deducted from tax liabilities as a legitimate business expense. Another would be to switch regulatory control over tobacco products and alcoholic beverages to the Food and Drug Administration from the Federal Trade Commission. Fourth, because cigarette use is the most visible and detectable gateway drug, special efforts should be made to restrict areas where this behavior might occur. For example, prohibition of smoking on campus and strict restrictions about leaving campus or returning to a vehicle might accomplish this goal. There is a fifth tactic and strategy that should be considered in every school district and individual school. It involves recognition of the fact that
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nicotine is an addicting drug and that, for teachers and students, school is a worksite. There is increasing pressure in all sectors of society to make our workplaces "drug free" which includes schools. The 1988 Surgeon General's report is clear--nicotine is an addicting drug, as addicting as heroin or cocaine. The data presented above demonstrated the extent to which cigarette smoking is connected with the use of other drugs. In data not presented here, the strengths of the correlations for adults mirror those found in Table 2. The task of making schools a smoke free work environment for teachers and students may not be as difficult as it may seem. In fact, among all adults interviewed in the 1985 National Household Survey on Drug Abuse, those who classified themselves as teachers had a lower current smoking rate (14.7%) than other adults in general (34.7%). In addition to the lower prevalence rates for smoking among teachers, the emergence of truly "successful" and scientifically based smoking cessation programs offer significant hope for those dependent on nicotine. While there may be some who would rather "fight than switch," it is now possible to become a nonsmoker with less pain and a greater probability of long-term success. If we are really serious about drug use among adolescents in the United States, the only feasible and logical direction for public policy is not toward legalization, but it is toward a tougher stance regarding the so-called "legal" drugs. Through explicit prevention efforts in the schools and stronger efforts to control the environment, perhaps we can narrow the openings provided by the gateway drugs and reduce the probabilities of transition to marijuana, cocaine, and heroin.
REFERENCES Donovan, J., and Jessor, R. (1983). Problem drinking and the dimension of involvement with drugs: A Guttman scalogram analysis of adolescent drug use. American Journal of Public Health, 73, 543-552. Flay, B. R., Kopke, D., Thomson, S. J., Santi, S., Best, J. A., and Brown, K. S. (1989). Six year follow-up of the first Waterloo school smoking prevention trial. American Journal of Public Health, 79, 1371-1376. Henningfield, J. E., Clayton, R., and Pollin, W. (1990). Involvement of tobacco in alcoholism and illicit drug use. British Journal of Addiction, 85, 279-292. Inciardi, J. A., and McBride, D. C. (1989). Legalization: A high risk alternative in the war on drugs. American Behavioral Scientist, 32, 259-289. Johnston, L. D., Bachman, J. G., and O'Malley, P. M. (1990). Drug Use, Drinking, and
Smoking: National Survey Results from High School, College, and Young Adult Populations 1975-1989. Rockville, MD: National Institute on Drug Abuse. Kandel, D. B. (1975). Stages in adolescent involvement in drug use. Science, 190, 912-914. Kandel, D. B., Davies, M., and Raveis, V. H. (1985). The stressfullness of daily social roles for women: Marital, occupational, and household roles. Journal of Health and Social Behavior, 26, 64-78.
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National Institute on Drug Abuse. (1988). National Household Survey on Drug Abuse: Highlights, 1988. Rockville, MD: National Institute on Drug Abuse. National Institute on Drug Abuse. (1988). Main Findings: National Household Survey on Drug Abuse, 1985. Rockville, MD: National Institute on Drug Abuse. O'Donnell, J. A., and Clayton, R. R. (1982). The stepping stone hypothesis--marijuana, heroin, and causality. Chemical Dependencies, 4, 229-241. Pentz, M. A., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., Hansen, W. B., Wang, E. Y. I., and Johnson, C. A. (1989). A multicomponent community trial for primary prevention of adolescent drug abuse. Journal of the American Medical Association, 261, 3259-3266. Surgeon General of the United States. (1988). The Health Consequences of Smoking: Nicotine Addiction. Washington, D. C.: U.S. Government Printing Office. Wagenaar, A. C., and Streff, F. M. (1990). Public opinion on alcohol policies. Journal of Public Health Policy, 11, 189-205. Warner, K. E. (1989). Effects of the antismoking campaign: An update. American Journal of Public Health, 79, 144-151. Yamaguchi, K. and Kandel, D. B. (1984a). Patterns of drug use from adolescence to young adulthood: II. Sequences of progression. American Journal of Public Health, 74, 668-672. Yamaguchi, K., and Kandel, D. B. (1984b). Patterns of drug use from adolescence to young adulthood: III. Predictors of progression. American Journal of Public Health, 74, 673-681.
The Prevention of Drug Use Among Youth: Implications of "Legalization" Richard R. Clayton, Ph.D. 1 and Carl G. Leukefeld, D.S.W. z
This paper examines what would happen if marijuana were legalized in the United States. KEY WORDS: Gateway drugs; legalization; youth.
INTRODUCTION The primary purpose of this paper is to examine the implications of "legalizing" marijuana on primary prevention efforts in the United States. The goals of "primary" prevention are to increase the percentage of young people who choose to "never" use drugs and, for those who do choose to use drugs, to delay the onset of use. Further, the goal is to reduce the percentage who progress to more intensive and extensive use within drug classes and to decrease the percentage who progress across drug classes. We have chosen the "gateway" drugs phenomenon to set the context for what would happen if marijuana were legalized in the United States. We have also chosen to focus on gateway drugs because there is so much misinformation about the process by which people become increasingly more involved with drugs. Therefore, the first section of this paper will review what is known about the "gateway" drugs nicotine (cigarettes is the proxy here), alcohol, and marijuana. 1Richard R. Clayton, Ph.D., is Professor of Sociology and Psychiatry, and Scientific Director, University of Kentucky. Address correspondence and reprint requests to: Center for Prevention Research, University of Kentucky, 147 Washington Avenue, Lexington, KY 40506-0402. 2Carl G. Leukefeld, D.S.W., is Professor of Psychiatry and Director, Multidisciplinary Center on Alcohol and Drug Abuse, University of Kentucky. 289 © 1992Human Sciences
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THE "GATEWAY" DRUGS: "DEVELOPMENTAL" STAGES OF DRUG USE
Health educators, other teachers, and parents are all participants in systems built on "developmental" assumptions. For many of us, Piaget, Erickson, Kohlberg, and Havighurst are familiar names--the philosophical founders of what we do each and every work day. We believe that learning is both deductive and inductive, that what is taught and learned in one grade, or at one age, is carried forward and expanded, enlarged, enhanced, and reinforced in subsequent grades and ages. Over time we have learned that behavior, like cognitive functioning, occurs in developmental stages. In 1975 Denise Kandel, a sociologist at Columbia University, first identified the "developmental stages" of drug use. She observed, and correctly, that there is a distinct pattern or stages of initiation into the use of drugs. These stages are: 1, No use of any drugs 2. Use of beer or wine 3. Use of cigarettes and/or hard liquor 4. Use of marijuana 5. Use of other illicit drugs such as heroin and cocaine It is important to note that not all people go through these stages. Some people never begin using drugs--they stay at stage 1. Some enter stages 2 and 3, but never go on to using "illicit" drugs. Over the past 25 or so years, a substantial percentage of Americans have experimented with marijuana. Many who have tried marijuana have used it a few times and stopped, while others have continued to use it and perhaps have become even heavier users. However, some have gone on to use cocaine and/or heroin. Thus, one conclusion to be reached from Kandel's developmental stages approach is that onset of drug use is very patterned. Very rarely does someone use cocaine without previously using drugs in the prior stages. In fact, Kandet and others (Yamaguchi and Kandel, 1984a, 1984b; O'Donnell and Clayton, 1982; Henningfield, Clayton, and Pollin, 1990) have shown that marijuana use is essentially a "necessary" condition for the occurrence of cocaine use. Almost no one uses cocaine who has not previously used marijuana. This may not always have been true, but it is certainly true now and has been the case for at least the past 25 years. This does not mean there are no exceptions. There are certainly some who have used cocaine and not previously used marijuana or other gateway drugs, but they are exceedingly rare. The overwhelming majority of those who make it to the latter developmental stages have progressed through the prior stages.
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A second conclusion is that movement to more serious stages of drug use is probabilistic. The more extensive, the more intensive, the longer one uses drugs such as marijuana, the more likely it is that a person will begin to use drugs such as cocaine and heroin. The process here is not one of certainty, but rather one of probability. Not everyone who uses marijuana, even extensively, uses cocaine. In subsequent work, Kandel, Davies, and Raveis (1985) have suggested that there may be another stage between use of marijuana and use of other illicit drugs (i.e., use of prescription drugs such as tranquilizers, sedatives, stimulants, or analgesics). This stage, if it exists, is probably more likely to occur for females than males because of the differential prevalence by gender of benzodiazepine use. John Donovan and Richard Jessor, psychologists at the University of Colorado, have suggested that "problem drinking" may occur as a stage between use of marijuana and use of other illicit drugs (1983). This illustrates an important aspect of the developmental stages approach to drug use. When someone reaches stage 4, marijuana use, they continue and often have increased their use of those drugs at earlier stages: alcoholic beverages and cigarettes.
NUMBER OF YOUTH WHO USE DRUGS The data shown in Table 1 are from the 1985 National Household Survey on Drug Abuse, the 8th survey in this particular series of studies. The 12-17 year olds were chosen to be representative of all young people those ages who live in households in the continental United States. They were personally interviewed in a private setting within their homes and were guaranteed the confidentiality of their responses. Other analyses not presented here suggest that the overwhelming majority of these students provided honest answers to the questions.
USE OF MARIJUANA AND COCAINE The first and most obvious conclusion from these data is that these youth, representative of the "general" population, have not been insulated from illicit drugs. Close to 1 in 4 of all 12 to 17 year olds have tried marijuana. Involvement with marijuana is clearly a developmental phenomenon with 5.8% of the 12 to 13 year olds having tried it compared to 23.4% of the 14 to 15 year olds and 40.4% of the 16 to 17 year olds. These are very large jumps in lifetime prevalence indicating that the 9th, 10th, and l l t h
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Table I. Percentage of 12 to 17 Year Olds Reporting Lifetime, Past Year, Past Month Use of Cigarettes, Alcohol, Marijuana, Cocaine: National Household Survey on Drug Abuse 1985
Drugs and Age Groups
Lifetime
Past Year
Past Month
Cigarettes All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
45.2% 27.8% 47.1% 59.4%
25.8% 13.8% 26.0% 36.8%
15.3% 5.9% 14.3% 25.3%
Alcohol All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
55.5% 27.5% 61.0 75.8%
51.7% 24.2% 57.0% 71.8%
31.0% 10.8% 34.7% 45.9%
Marijuana All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
23.6 5.8% 23.4% 40.4%
19.7% 4.8% 20.4% 33.1%
12.0% 3.5% 11.0% 21.0%
Cocaine All 12-17 year olds 12-13 year olds 14-15 year olds 16-17 year olds
4.9% 0.5% 4.6% 9.4%
4.0% 0.5% 4.1% 7.4%
1.5% a 1.0% 3.2%
aLess than one-half of one percent.
grades are particularly important, a time when youth are quite vulnerable to initiation into marijuana use. It is also important to note that the majority of 16 to 17 year olds have not tried marijuana. The second conclusion is that use in the month preceding the interview was not rare. Slightly over 1 in 5 of 16 to 17 year olds used marijuana in the prior 30 days as did slightly over 1 in 10 of 14 to 15 year olds. These facts suggest that any and all prevention efforts directed at youth face formidable challenges. The rates are obviously much lower for cocaine, but still illustrate the age-graded developmental patterns of initiation into this very dangerous drug. In data not shown here, an even more serious pattern of cocaine use emerged. When the sample was limited to just those who had ever used cocaine, 44% of 12 to 17 year olds reported having "smoked" or "freebased" cocaine at some time in their life. Among adults 18-25, 26-34, or 35 years old and older who had ever used cocaine, approximately 20% had smoked or freebased it (NIDA, 1988).
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These are dramatic differences. They are startling because the quickest way to get a drug to the brain is by smoking it. Within seven seconds after inhaling the smoke or vapors from cocaine receptor sites in the brain are detecting the drug. While the percentage of youth reporting having used cocaine is "relatively" low, any level of use of this dangerous drug is too high. If, in addition, the way they are using the drug is one of the more dangerous "routes of administration," there is greater cause for concern.
USE OF ALCOHOL AND CIGARETTES In every state, alcohol and cigarettes are "illicit" drugs for persons under the age of either 18 or 21. While alcohol use in particular is woven into many of our rituals and everyday events of adult life, these drugs should not be legally available to our youth. The data in Table 1 show just how widely the law is violated with regard to alcohol by young people in the United States. Over 1 in 10 youth 12 to 13 years old had used alcohol in the month preceding the interview while the figures were over 1 in 3 for 14 to 15 year olds and close to 1 in 2 for 16 to 17 year olds. The magnitude of these figures illustrate why alcohol is implicated in many of the fatalities among youth and why so many youth with seemingly "unlimited" potential fail to achieve. The 1988 report from the Surgeon General on Smoking and Health provided reams of evidence confirming what virtually all long term smokers know all too well - nicotine is a very addicting drug. The Surgeon General's report indicates that nicotine may be as addicting as heroin or cocaine. In graphic terms, a cigarette is just as much a drug delivery system as a crack pipe or a hypodermic needle. The data in Table 1 show that over 1 in 4 youth 12 to 13 years old have tried cigarettes and 5.9% had smoked cigarettes during the month prior to the interview. The rates are higher the older the student such that 1 in 4 (25.3%) 16 to 17 year olds reported smoking in the previous month.
THE CONCEPT OF CAUSALITY If you were asked whether smoking "causes" lung cancer or cardiovascular disease, your answer would probably be: "Of course, everybody knows that!" The Surgeon General used criteria commonly accepted by scientists in many disciplines to establish these "causal" relationships. The first and perhaps most important criterion of causality is correlation. How-
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ever, just because two things are correlated does not mean they are "causally" related. For example, even though the heat of the sidewalks in New York City is statistically correlated with the homicide rate, we wouldn't claim the temperature is the "cause" of the murder rate. Correlation as a basis for claiming causality must be statistical AND logical. In addition to the relationship being "logical," at least two other criteria of causality must be satisfied: (a) the presumed "cause" must occur prior to the presumed "effect," and (b) alternative explanations for the relationship between the presumed cause and the presumed effect must be eliminated (i.e., testing for spuriousness). For example, before one can claim that smoking causes lung cancer, it is necessary to eliminate the possibility that genetic and other environmental factors were responsible for the statistical relationship (i.e., correlation) between smoking and lung cancer.
GATEWAY DRUGS AND CORRELATION There are two very important facts related to the gateway drugs phenomenon. First, the stages of initiation into use of various drugs (i.e., the sequencing of onset) is consistent across many different kinds of groups. In the overwhelming majority of cases, cigarette and alcohol use precede marijuana use which almost invariably precedes use of other drugs such as cocaine. Therefore, temporal order of onset is not an issue for debate. The data in Table 2 show the degree to which use of these gateway drugs are correlated. The data are all for "past month" use of the drugs. As the data show clearly, those who have used the gateway drugs--marijuana, alcohol, or cigarettesmduring the past month are considerably more likely than those who have not used them to report using other drugs. For example, 10.5% of the past month users of marijuana report past month use of cocaine compared to less than one-half of one percent of those who had not used marijuana in the past month. However, from the perspective of a teacher or school administrator, this information is difficult to translate into something practical. People often go to great lengths to conceal their marijuana and cocaine use. Alcohol use is also clearly related to use of other drugs. For example, 32.3% of past month users of alcohol report past month use of marijuana compared to 2.8% of those who had not had anything to drink in the past month. This information is again interesting but may have limited practical utility. Most underage students restrict their drinking to nighttime and/or weekends.
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THE IMPORTANCE OF CIGARETI?ES AS A GATEWAY DRUG
However, the data in Table 2 concerning cigarette use and use of other drugs provide the same story but with different practical implications. The size of difference between two percentages is an indication of the degree of correlation. This is called a "delta" value. The delta value or correlation between cigarette smoking and marijuana use is strong: 47.7% compared to 5.5%. To make this more graphic, consider the following illustration. A representative sample of 100 students 12-17 years old is standing on the 50 yard line in the football stadium. When you ask those who have smoked one or more cigarettes during the past month to set forward, 15 will do so. If the entire group, all 100, were asked to raise their hands if they smoked any marijuana during the previous 30 days, 7 of the 15 cigarette smokers would raise their hands while only 5 of the 85 nonsmokers would do so. Does this mean that cigarette smoking is "causally" related to marijuana use? This question can't be answered definitively without applying the other statistical and logical criteria used in testing for causality. However, we often act or react in our professional and personal lives according to observed correlations without solid and irrefutable evidence that two phenomena are "causally" related. We do this as parents when our children get involved with someone we consider to be a potentially bad influence. We do the same thing with young people in our classrooms. Shouldn't we do the same with this information on smoking and other drug use? If we are serious about drug abuse prevention and intervention, the most effective predictor o f who is using marijuana may be who is using cigarettes. One could predict with a fair degree of accuracy that almost one-half of students who are current cigarette smokers are also current marijuana users. We don't need to have a self-esteem score or some measure of personality to know who is at high risk for using "illegal" drugs; why not do like the toucan bird on the cereal commercial--"just follow your nose." Cigarette smoking is a visible behavior not usually concealed by students. Smokers can be seen on almost any campus before and after school. In fact, even a blind person could find the smoking area and spot the smokers in the halls using his or her sense of smell.
THE IMPLICATIONS OF A LEGALIZATION POLICY FOR PRIMARY PREVENTION
We were asked to review the effects marijuana legalization would have on drug abuse prevention efforts in the United Sates. We believe le-
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Table 2, Past Month Use of Cigarettes, Alcohol, and Marijuana and Past Month Use of Other Drugs Among 12 to 17 Year Olds: National Household Survey on Drug Abuse 1985
Cigarettes Past month use of Cigarettes Alcohol Marijuana Pillsa Cocaine
No (84.7%)
Yes (15.3%)
23.3% 5.5% 1.4% b
73.5% 47.7% 12.4% 8.2%
Alcohol
Marijuana
No (69.0%)
Yes (31.0%)
No (88.0%)
Yes (12.0%)
5.9%
36.4%
9.1% 23.9%
61.0% 83.8%
2.8% 0.7% b
32.3% 8.3% 4.7%
1.3% b
15.8% 10.5%
apills refers to nonmedical use of stimulants, sedatives, tranquilizers, or analgesics. bLess than one-half of one percent.
galization of marijuana in the U.S. is extremely unlikely by the federal government. However, in the sections below we make a serious attempt to examine the basic arguments offered for adopting legalization as a policy and offer arguments against this policy because of the potential impacts on efforts to "prevent" drug use. Finally, we will offer an alternative practical, and policy driven, approach to the problem of drug use among youth in the United States. One thing should be clear from the outset: We believe endorsement of a national policy of legalization is antithetical to preventing drug use.
BACKGROUND: FEDERAL DRUG POLICIES
Federal drug policies are usually discussed as SUPPLY REDUCTION and DEMAND REDUCTION. These two approaches are primarily relevant for current "illicit" drugs such as marijuana, heroin, cocaine, etc. These drugs constitute the focus of legalization discussions, and most of our attention in this paper is focused on these drugs; particularly marijuana. It should be noted that several states and communities have "legalized" the personal use of small amounts of marijuana, but none have done this for adolescents. There are policy approaches to other drugs, such as nicotine and alcohol, which are most appropriately classified as REGULATED. Products containing nicotine and alcohol are legal to produce, although the federal government regulates the production and marketing (i.e., supply) of tobacco through a price support and taxation system. Advertising and promoting to-
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bacco products is monitored and regulated by the federal government: a form of demand reduction. Laws and regulations at the federal, state, and local level attempt to regulate who may purchase products containing nicotine, where they may purchase them, and where these products may be consumed. With regard to alcohol, there are a number of regulatory policies concerning minimum age to purchase, types of alcoholic beverage products that may be purchased in specified circumstances, when these commodities may be sold, and consequences for persons who provide alcoholic beverages to guests/customers. In addition, products containing alcoholic beverages are taxed. Products containing nicotine and alcohol also contain specified warning labels. A fourth approach to drug policies involves REGULATION BY CONTROL. Here we refer to psychotherapeutic drugs such as the benzodiazepines and narcotic analgesics; drugs that may only be obtained legally via a prescription from a registered health care professional and prepared and distributed by a registered pharmacist. There are also drugs dispensed over-the-counter as pain killing agents which are regulated primarily in terms of required labeling. Drugs like caffeine are even used as marketing devices, caffeinated versus de-caffeinated products.
LEGALIZATION: WHAT'S IN A NAME? Different "labels" have been assigned to what is now called "legalization." During the Nixon administration, the National Commission on Marihuana and Other Drug Abuse endorsed a policy they called "partial prohibition" that would allow for regulated production and distribution of marijuana. That term was to some extent replaced by "decriminalization" which grew from the concern that many youth could be forever classified as drug abusers if prosecuted under laws which prohibited possession of even small amounts of marijuana. During the late 1970s and early 1980s, laws were changed in 11 states to classify possession of up to a certain amount of marijuana (the definition of "small" amount for personal use varied) as a "civil" rather than a "criminal" violation. One of the expressed goals of this policy change was a reduction in the number of criminal court cases being tried. At the time these "experiments" in drug use public policies were being implemented, some expected rapid diffusion of "decriminalization" into the remaining states. However, diffusion did not occur. In fact, no states have decriminalized marijuana since 1978. In this paper we focus on a policy of legalization and argue that such a policy is short sighted and illogical for the youth of our nation.
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LEGALIZATION: FLAWED ASSUMPTIONS 1. Current policies of prohibition have failed. The argument by the proponents of legalization that current policies have failed is usually based on two things. First, those who want to legalize are strongly opposed, in principle, to the use of criminal justice sanctions for so-called "victimless" crimes such as drug use. However, those who oppose legalization argue that drug use is not a victimless crime; the user, his or her family, and the society at large suffer major social and economic costs because of the user. Second, those who want to legalize drugs claim high prevalence use rates indicate widespread law violations which proves the lack of deterrence. However, there is clear indication from various general population surveys that most drug use rates are going down and have been since the late 1970s and early 1980s. In fact, Johnston, Bachman, and O'Malley (1990) indicate that the percentage of high school seniors who smoke marijuana daily is now less than 3%, down from its peak in 1979 of 11%, and even lower than it was in 1975 when this study was first conducted. The rates of cocaine use among high school seniors was also significantly lower in 1989 than it was in 1988 which continues a trend downward. Data from the 1988 National Household Survey on Drug Abuse (see NIDA, 1990) indicate significant decreases in most drug use. In addition, there has been a recent significant decline in cocaine as an identified drug in visits to emergency rooms. If current policies have failed, prevalence trends would be at least stable or increasing in order to justify a change in policy. Why would a society change the entire thrust of its drug policy orientation when the data consistently indicate "progress" in the desired direction of less among adolescents and others. 2. The American public is opposed to current policies and would prefer legalization to prohibition. The use of alcoholic beverages is very high among adults in this society; over three-fourths report some consumption of alcohol in the past 30 days. For them, alcohol use is "illegal." Wagenaar and Streff (1990), report results from a study of a representative sample of 760 Michigan adults. They found that even 74% of those who drank alcoholic beverages more than once a week were in favor of increasing excise taxes on alcohol and earmarking these funds to combat drinking driving. With the exception of frequent episodic heavy drinkers, large majorities favor prohibiting concurrent sales of alcoholic beverages and motor fuels. Two-thirds of the respondents favored immediate 90 day suspension of drivers' licenses upon arrest for driving over the legal limit. These are tough positions to be taken
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for a drug that is assumed to be woven into every aspect of American life. If this study is at all representative then why would anyone expect the positions toward currently illegal drugs to be changed. In fact, there is solid evidence from public opinion polls that attitudes toward legalization of marijuana have become less tolerant; not more tolerant (see Inciardi and McBride, 1989). To our knowledge, no credible data exist which suggest that the American public is in favor of legalizing marijuana or any other drug currently considered illicit.
AN ALTERNATIVE POLICY APPROACH: GET TOUGH ON THE LEGAL DRUGS We are always amazed and more than a little perplexed by those who argue for "legalization" of the currently illicit drugs. Their principal argument for legalization is that current government policies and programs have failed miserably. What is needed, they argue, is "regulation" of all drugs (i.e., control of the production, distribution, and revenue resulting from the sale of these drugs). Who will "regulate" these drugs? The answer is simple: the same government with new bureaucracies added for this purpose. But wait a minute. Isn't this the same government that they believe has failed with its current policies. Isn't this the same government that is supposed to regulate the distribution of the legal drug alcohol. According to the latest Monitoring the Future survey of high school seniors, 37% of all high school seniors report having had five or more drinks in a row on at least one occasion in the past two weeks. If we are not successfully regulating the distribution of alcohol, how can these critics of the current policy and its implementation, argue to add more drugs for governmental regulation? If our current efforts to curb drug use are not uniformly successful, legalization is not the only viable option. We could "get tougher on the legal drugs," particularly with regard to adolescent use.
IF WE ARE REALLY SERIOUS ABOUT DRUG PREVENTION If we really are serious about drug prevention in the United States, legalization is clearly not an answer. In fact, it is 180 degrees opposite. We already have at least two drugs, alcohol and nicotine, that are "legal" for adults which have major impacts on morbidity and mortality in the U.S. Norms about the nicotine use are changing in the desired direction. According to Warner (1989), there are 50 million instead of 91 million current
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smokers, because of consistent and strong anti-smoking efforts since 1964. As previously noted in the research conducted by Wagenaar and Streff (1990), it could be suggested that more stringent alcohol control policies and more strict sanctions against those who drink and drive are endorsed by a sizable majority of the American public. Given the social and economic costs attributable to alcohol and tobacco products, how could anyone argue persuasively to add another drug such as marijuana to that list, especially younger persons? However, it is also true that current procedures for limiting adolescent access to alcohol and tobacco products are not as effective as they might be. What can and could be done about these drugs? Several important considerations are discussed below. First, efforts at school based prevention interventions must be increased. A number of studies have demonstrated that it is possible to influence decisions to use or not use, or to continue or not continue to use cigarettes (see Flay et al., 1989; Pentz et al., 1990). However, these efforts are not sufficient to reduce the overall incidence and prevalence of cigarette use among youth. Efforts must also be made to alter the environment and norms concerning use of alcoholic beverages and tobacco products by adolescents. Second, availability is a major factor in the use of all types of drugs. For example, some communities have banned cigarette vending machines. This limits the number of outlets. This means that a young person who wants to purchase cigarettes must buy them from a person responsible for limiting access. Third, one of the problems with the so-called legal drugs is that they can be advertised. The tobacco industry spends close to $3 billion a year to get market share and brand loyalty. There are many who believe the real purpose of this advertising is to replace those who quit because of choice or by death. It is time to seriously consider greater restrictions on all advertising of these products. One strategy would be to progressively reduce the amount of advertising costs that can be deducted from tax liabilities as a legitimate business expense. Another would be to switch regulatory control over tobacco products and alcoholic beverages to the Food and Drug Administration from the Federal Trade Commission. Fourth, because cigarette use is the most visible and detectable gateway drug, special efforts should be made to restrict areas where this behavior might occur. For example, prohibition of smoking on campus and strict restrictions about leaving campus or returning to a vehicle might accomplish this goal. There is a fifth tactic and strategy that should be considered in every school district and individual school. It involves recognition of the fact that
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nicotine is an addicting drug and that, for teachers and students, school is a worksite. There is increasing pressure in all sectors of society to make our workplaces "drug free" which includes schools. The 1988 Surgeon General's report is clear--nicotine is an addicting drug, as addicting as heroin or cocaine. The data presented above demonstrated the extent to which cigarette smoking is connected with the use of other drugs. In data not presented here, the strengths of the correlations for adults mirror those found in Table 2. The task of making schools a smoke free work environment for teachers and students may not be as difficult as it may seem. In fact, among all adults interviewed in the 1985 National Household Survey on Drug Abuse, those who classified themselves as teachers had a lower current smoking rate (14.7%) than other adults in general (34.7%). In addition to the lower prevalence rates for smoking among teachers, the emergence of truly "successful" and scientifically based smoking cessation programs offer significant hope for those dependent on nicotine. While there may be some who would rather "fight than switch," it is now possible to become a nonsmoker with less pain and a greater probability of long-term success. If we are really serious about drug use among adolescents in the United States, the only feasible and logical direction for public policy is not toward legalization, but it is toward a tougher stance regarding the so-called "legal" drugs. Through explicit prevention efforts in the schools and stronger efforts to control the environment, perhaps we can narrow the openings provided by the gateway drugs and reduce the probabilities of transition to marijuana, cocaine, and heroin.
REFERENCES Donovan, J., and Jessor, R. (1983). Problem drinking and the dimension of involvement with drugs: A Guttman scalogram analysis of adolescent drug use. American Journal of Public Health, 73, 543-552. Flay, B. R., Kopke, D., Thomson, S. J., Santi, S., Best, J. A., and Brown, K. S. (1989). Six year follow-up of the first Waterloo school smoking prevention trial. American Journal of Public Health, 79, 1371-1376. Henningfield, J. E., Clayton, R., and Pollin, W. (1990). Involvement of tobacco in alcoholism and illicit drug use. British Journal of Addiction, 85, 279-292. Inciardi, J. A., and McBride, D. C. (1989). Legalization: A high risk alternative in the war on drugs. American Behavioral Scientist, 32, 259-289. Johnston, L. D., Bachman, J. G., and O'Malley, P. M. (1990). Drug Use, Drinking, and
Smoking: National Survey Results from High School, College, and Young Adult Populations 1975-1989. Rockville, MD: National Institute on Drug Abuse. Kandel, D. B. (1975). Stages in adolescent involvement in drug use. Science, 190, 912-914. Kandel, D. B., Davies, M., and Raveis, V. H. (1985). The stressfullness of daily social roles for women: Marital, occupational, and household roles. Journal of Health and Social Behavior, 26, 64-78.
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National Institute on Drug Abuse. (1988). National Household Survey on Drug Abuse: Highlights, 1988. Rockville, MD: National Institute on Drug Abuse. National Institute on Drug Abuse. (1988). Main Findings: National Household Survey on Drug Abuse, 1985. Rockville, MD: National Institute on Drug Abuse. O'Donnell, J. A., and Clayton, R. R. (1982). The stepping stone hypothesis--marijuana, heroin, and causality. Chemical Dependencies, 4, 229-241. Pentz, M. A., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., Hansen, W. B., Wang, E. Y. I., and Johnson, C. A. (1989). A multicomponent community trial for primary prevention of adolescent drug abuse. Journal of the American Medical Association, 261, 3259-3266. Surgeon General of the United States. (1988). The Health Consequences of Smoking: Nicotine Addiction. Washington, D. C.: U.S. Government Printing Office. Wagenaar, A. C., and Streff, F. M. (1990). Public opinion on alcohol policies. Journal of Public Health Policy, 11, 189-205. Warner, K. E. (1989). Effects of the antismoking campaign: An update. American Journal of Public Health, 79, 144-151. Yamaguchi, K. and Kandel, D. B. (1984a). Patterns of drug use from adolescence to young adulthood: II. Sequences of progression. American Journal of Public Health, 74, 668-672. Yamaguchi, K., and Kandel, D. B. (1984b). Patterns of drug use from adolescence to young adulthood: III. Predictors of progression. American Journal of Public Health, 74, 673-681.
