Stanton and Archie Brodsky tackle popular temperance messages in America whose goal is to discredit, disqualify, and discourage all consumption of all psychoactive substances--as though the issue were not self-evidently what, how, and by whom all such substances are used. And they will be used--both the legal and illegal ones! Facing this fundamental reality, distinguishing among types of use, and educating young people about these differences is exactly the opposite approach to the one taken by Joseph Califano's neoTemperance CASA and its supporters.
Published in Addiction Research, 5:419-426, 1998.
© 1998 Overseas Publishers Association.
Reprinted with permission from Gordon and Breach.
Gateway To Nowhere
How Alcohol Came to be Scapegoated for Drug Abuse
New York City
Department of Psychiatry
Harvard Medical School
The "gateway" theory of drug use holds that exposure to "entry" drugsnotably alcohol, cigarettes, and marijuanareliably predicts deeper and more severe drug involvements. U.S. drug czar Barry McCaffrey has incorporated the gateway theory as an integral part of the country's drug policy. However, although most heavier drug users undoubtedly were once lighter drug users, this association does not establish a causal connection. Few young people progress from lighter to heavier drug use; in fact, the dominant trend is for young people to reduce illicit drug use and to stabilize drinking with maturity. The gateway theory may actually be counterproductive if we consider that in non-temperance cultures that manage alcohol successfully, alcohol is generally introduced to young people at an early age. Other evidence suggests that moderate-drinking and drug-using young people, even when such behavior is illegal, are better off psychologically and are more likely to make a successful transition to adulthood than abstainers. Overriding all such profiles of moderate and abusive users of drugs and alcohol are social-epidemiologic models which indicate that the best predictors of abusive substance use are social, family, and psychological depredations that occur independent of supposed gateway linkages.
Keywords: Gateway drug; gateway behavior; stepping-stone drug; temperance; moderate drinking; problem-behavior theory; alcohol; marijuana; cigarette smoking; adolescent
The National Drug Control Strategy for 1997 unveiled by U.S. drug czar Gen. Barry R. McCaffrey (Office of National Drug Control Policy, 1997) adopts a "zero-tolerance" policy toward youthful alcohol, tobacco, and marijuana use. The strategy regards all of these as "gateway behaviors" leading to serious drug abuse. In support of this contention, the Strategy cites a report by the Center on Addiction and Substance Abuse (CASA, 1994) entitled Cigarettes, Alcohol, Marijuana: Gateways to Illicit Drug Use. The CASA report has been widely influential, in part because CASA president Joseph A. Califano, Jr., is a former Secretary of the U.S. Department of Health, Education, and Welfare.
Califano and CASA relied on data from a 1991 government survey to show that both adolescents and adults who have used cigarettes, alcohol, and marijuana are hundreds of times more likely to use cocaine than those who have never used any of the three substances. Califano's conclusion: The most critical step in stamping out dangerous drug abuse is to prevent young people from embarking on the road to perdition through the gateway of smoking, drinking, or using marijuana.
According to The National Drug Control Strategy, "Drug policy must be based on science, not ideology." This pronouncement is belied by the document's uncritical reliance on the "gateway" concept, whose enthusiastic acceptance by public officials and agencies has not been accompanied by any real scientific scrutiny. For example, the findings of the annual national surveys of high-school student drug use conducted at the University of Michigan over the past two decades offer little support for the gateway theory; instead, they show historical fluctuations in drug use. No one has shown a consistent pattern of youthful alcohol, marijuana, and cigarette use trends that presages cocaine and heroin use trends (Zimmer and Morgan, 1997).
The 1996 survey results (Johnston et al., 1997) continued a recent mild upward trend in use of marijuana, but not other illegal drugs. Along with a slight upturn in marijuana use among high school seniors, tobacco use was also up, while "binge" drinking (five or more drinks at one time within the past two weeks) remained at roughly the same level (30 percent of high school seniors) in 1996. Although the incidence of such drinking is lower than the highs of over 40 percent in the late seventies and early eighties, this does not signify a lessening of overall alcohol excess among young Americans. Researchers at the Harvard School of Public Health have labelled 44 percent of U.S. college students as binge drinkers (50 percent of men had 5+ drinks, 39 percent of women had 4+ drinks) (Wechsler et al., 1994). What lies in store for these young people as they mature?
When young people get away from home by going to college, their binge drinking rises; in time, however, their drinking declines (as does their drug use) as they assume adult roles (Bachman et al., in press). Given that so many young people ultimately do moderate their drinking, why are we failing so badly with the prohibitionist alcohol-education message in which Gen. McCaffrey places such confidence? This failure has more than temporary consequences. Unfortunately, despite the overall drop-off from early problem drinking, a higher than average percentage of those who display unhealthy early drinking will develop adult drinking problems (Schulenberg et al., 1996).
The reign of ideology
It is not news that the government and government-related agencies want to prevent everyone from using illegal drugs and young people from sampling legal substances, such as alcohol, as well. As a part of this campaign, the Califano report marked a well-worn tendency to oversimplify complex matters and to tell people what they want and expect to hear. Remember that Robert L. DuPont, an anti-drug activist (he testifies, for example, on behalf of school systems seeking to implement drug tests), former White House drug chief, and the first director of the National Institute on Drug Abuse, was the first to popularize the gateway concept in 1985, with his book, Getting Tough on Gateway Drugs: A Guide for the Family.
Warnings against gateway or "stepping-stone" drugs are standard practice by educators, the media, and public-health advocates. These alarmist warnings fuel the War on Drugs in its most indiscriminate form. Hearing of the gateway theory, we may hesitate to teach teenage children to drink responsibly. We begin to fear that exposing them to mild, positive drinking will open the floodgate and sweep them into the crack house.
What makes far more sense is to acknowledge the obvious to childrenthat there is healthy and unhealthy drinking. Both research and common sense tell us that the young people least likely to drink disruptively are those who were introduced to alcohol by moderate-drinking parents, rather than being initiated into drinking by their peers. Vaillant (1983) found that young Italian-American men tracked from adolescence were only one-seventh as likely to become alcoholics in adulthood as neighboring Irish-Americans in Boston. Yet, it was the Italian-American families who introduced children to alcohol in a family context early in life, while the Irish-Americans urged children to abstain. Likewise, children who learn to drink wine at family social and religious ceremonies are not likely to be found taking crack on our city streets.
But reasonable souls who wouldn't mind having their kids learn in school that alcohol is a normal amenity of life for adults who can use it in moderation are out of luck, at least in the United States. Although Prohibition ended in the U.S. sixty years ago, only drug-education programs with an uncompromisingly prohibitionist messageeven toward alcoholcan be federally funded. On Main Streets across America, billboards and banners proclaim to our young that "Alcohol Is A Liquid Drug." This announcement provides no useful guidance for coming to terms with a substance that is legal, and that most Americans currently use.
The gateway theory also leads to the coercive treatment of many adolescents. In his book The Great Drug War, Arnold Trebach (1987) described how 19-year-old Fred Collins was pressured into residential treatment at Straight Inc. in Florida. Confined for four months, Collins was subjected to constant surveillance and indoctrination, accompanied by sleep and food deprivation. Collins escaped, and a jury awarded him $220,000 from Straight. At the trial, Collins was shown to have occasionally indulged in beer and marijuana. But to many in the treatment community, this "proved" he was headed for the disaster of addiction.
Collins embodies the gateway model's credibility gapthe disparity between the image and the reality of mainstream youth who start down the supposed primrose path to chemical enslavement. He illustrates, too, the costs of trying to make the relatively benign reality conform to the malign image. Among these costs are needless grief for parents and children and money wasted on unnecessary or ineffective treatment. At the same time, frightening warnings that young people can plainly see are untrue lead most to dismiss useful and realistic messages about harmful alcohol or drug use. After all, today's college students, nearly half of whom are binge drinkers, have been shaped by years of anti-drug and anti-alcohol education programs.
A misleading oversimplification
The cause-and-effect relationships that Califano's report took to be self-evident are in fact the subject of much scholarly debate. As (New York) City University Medical School pharmacologist John Morgan and his colleagues (1993, p. 217) noted, "This gateway concept seems to resemble driving slowly and safely as a gateway to driving recklessly and unlawfully. The reckless driver has always driven carefully at some point. How often does careful driving proceed to recklessness and does the careful driving cause the recklessness?"
It is true that users of narcotics and cocaine typically smoke cigarettes, drink alcohol (often to excess), and use other drugs as well. That is hindsight; looking from the other direction, adolescents and young adults who have had some experience with tobacco, alcohol, and marijuana are somewhat more likely to try "hard" drugs as well. But these generalizations do not mean that "soft" drug use causes, or even predisposes, a young person to use "hard" drugs.
One of the most prominent gateway advocates is epidemiologist Denise Kandel of Columbia University. But Kandel (1989) takes pains to point out that most youths stop at some point on the progression to hard drugs. Even among those who misbehave with drugs and alcohol, most eventually stop using drugs and moderate their alcohol use. Few of the teenagers who drink, even with the problems this causes, will turn into chronic problem drinkers, let alone crackheads. What we really need to figure out is who those few are who progress to extreme drug use, and what distinguishes them from the majority who would never even consider passing through the gateway.
An enduring myth
For what is at best a shallow half-truth, the notion of an inexorable progression from tasting forbidden fruit to self-destruction has had a remarkably enduring appeal for Americans. Its roots lie in the nineteenth-century Temperance movement's image of "the fatal glass of beer"that first sip taken by the innocent farm boy in the sinful city. The Currier & Ives print "The Drunkard's Progress" was one of many temperance tales that began with a man tippling and ended in suicide or murder.
Although Prohibition's repeal discredited the idea that alcohol addicts any and every user, this magical potency was then transferred to narcotics. At the same time, marijuana was misclassified as a narcotic. When marijuana became a staple on college campuses in the 1960s and 1970s, however, this myth also had to be discarded. But marijuana continued to be demonizedonly now as a stepping-stone to heroin addiction. Eventually, alcohol and cigarettes were made additional stepping stones to drug addiction. Thus, we still see the shadow of "the fatal glass of beer" in the title of an article by Kandel and Yamaguchi (1993) in The American Journal of Public Health, "From Beer to Crack."
But this model of drug use succeeds little better than the temperance version. In the Harvard alcohol survey, seven in ten students had drunk in the last month. But according to a 1994 government survey, only 12 percent of 18-25-years-olds and 6 percent of 12-17-year-olds had taken marijuana during the past month, only 1 percent of 18-25-year-olds and 0.3 percent of 12-17-year-olds had taken cocaine, and far fewer had taken crack or heroin (National Household Survey on Drug Abuse, 1996). Based on such information, the stepping-stone theory had to be watered down into the notion of gateway drugs. In this view, alcohol and cigarettesalong with marijuanadon't guarantee, but only make it more likely, that some will use harder drugs.
But even this revision doesn't work. If a substantial segment of Americans have used marijuana for years without getting involved with other illegal drugs, then not only is the old stepping-stone theory a shibboleth, but so too the weaker gateway version. What is true of marijuana is even more true of alcohol, since such a large majority of Americans have drunk. And a study from the National Development and Research Institutes (Golub and Johnson, 1994) found that the relationship between alcohol use and more serious drug abuse has been decreasing during the past three decades.
Alcohol, which can be used in a variety of healthy and unhealthy ways, is just too mainstream to be connected reliably to drug use. This has been truer the more illicit drugs have been marginalized. Cultural myths die hard, but the fatal-glass myth has lingered particularly long. It is time to pull the plug on it. To do something about the destructive consequences of drug abuse, we need to jettison entirely our temperance mentality.
Easy image, hard reality
The Califano report conjures up an "Invasion of the Body Snatchers" image of America, as beer and cigarettes steal the souls of innocent children. This latter-day "Demon Rum" scenario is just another case of looking for our keys under the street light rather than where we actually lost them. For the hard reality to which all research points is that some young people are more vulnerable to destructive habits than others. They are more vulnerable because of psychological maladjustment, family disruption, and economic and social deprivation. For example:
- Kandel (1989) identified depressive symptoms, parental drug use, and the lack of a close parent-child relationship as risk factors for progressing to more serious drug use.
- Sociologist Richard Clayton (1985) found that truancy was a strong prior predictor of cocaine use among high-school students independent of any other substance use.
- Grace Barnes (1987) of the New York State Division of Alcoholism and Alcohol Abuse found that children from broken homes were far more likely to use illicit drugs. However, single parents could overcome this risk by providing "appropriate levels of nurturance and control."
The focus should not be on gateway drugs but on the highly dysfunctional lives of adolescent drug abusers. Two UCLA psychologists, Michael Newcomb and Peter Bentler (1989), found that the most destructive teenage drug use occurred among youths whose lives were characterized by limited opportunities (often resulting from inner-city conditions), internal emotional distress, and unhappiness. Among those in the inner city, even when they were able to stop taking drugs, their lives in other respects (e.g., crime, early pregnancy) did not improve. UC Berkeley psychologists Jonathan Shedler and Jack Block (1990) actually found that young people who experimented with drugs were better adjusted than frequent users and abstainers. These researchers were also able to predict drug problems for teens based on psychological profiles constructed when the subjects were small children! More recently, Pape and Hammer (1996) found a similar pattern with respect to alcohol use by male adolescents in Norway: that those who got drunk for the first time at either a very early or a late age had elevated levels of psychological problems; those who first got drunk in mid-adolescence were most likely to develop normally.
The lives of young people at serious risk for drug abuse have been best described by the problem-behavior theory of University of Colorado psychologist Richard Jessor (1987). Jessor has shown that drug abuse is one of a cluster of problem behaviors that also include truancy, delinquency, unhealthy eating habits, excessive TV watching, reckless driving, and premature or reckless sexual behavior. These behaviors do not cause one another; rather, they are common manifestations of traumatized and aimless lives.
Looked at from the opposite direction, Donovan and Jessor (1985) find the risk of problem behavior is reduced by high self-esteem, a sense of personal control, placing a high value on health, and participation in constructive mainstream activities such as school and church. Jessor and his colleagues summed up some of these positive factors as "an orientation toward, commitment to, and involvement with the prevailing values, standards of behavior, and established institutions of American society" (Costa, Jessor, and Donovan, 1989, p. 842).
Directions for policy
A drug policy based on the mechanistic "gateway" model is a policy badly in need of reconsideration. It should be replaced by one grounded in a real understanding of why people use and abuse drugs. After decades of continuous effort, we still face substantial drug use among young people, including periodic rises like that noted in the Michigan survey. Obviously, the ultimate solution for youthful drug abuse and much else ailing America is to strengthen personal values and family lives and to allow more people to buy into the American dream. But, while we struggle to achieve this elusive goal, we can try to do the following:
- Acknowledge the difference between exposure to drugs and drug abuse, and especially between controlled and destructive drinking.
- With those young people most at risk for becoming involved with drugs, warnings to avoid any use of drugs, alcohol, and cigarettes have thus far been futile. It is more useful to require (and help) them to take responsibility for their actions, to escape destructive situations, and to contribute to society.
No drug makes people use it or other drugs. The causes of drug abuse are life conditions that motivate people to act destructively toward themselves and others. Liberals identify these as social and economic circumstances involving a loss of opportunity and hope. Conservatives identify them as a breakdown of moral standards and public order. Either of these explanations has a lot more going for it than Demon Rum.
Preparation of this article was supported by a small grant from the Weinberg Consulting Group.
Bachman, J. G., Wadsworth, K. N., O'Malley, P. M., Johnston, L. D. and Schulenberg, J. E. (in press). Smoking, Drinking and Drug Use in Young Adulthood: The Impacts of New Freedoms and Responsibilities. (Erlbaum, Mahwah, NJ.)
Barnes, G. M. and Windle, M. (1987). "Family factors in adolescent alcohol and drug abuse," Pediatrician, 14, 13-18.
Center on Addiction and Substance Abuse at Columbia University (1994). Cigarettes, Alcohol, Marijuana: Gateways to Illicit Drug Use. (Author, New York.)
Clayton, R. R. (1985). Cocaine use in the United States: In a blizzard or just being snowed? In N.J. Kozel and E.H. Adams (eds.), Cocaine Use in America: Epidemiologic and Clinical Perspectives. (National Institute on Drug Abuse, Rockville, MD), pp. 8-34.
Costa, F. M., Jessor, R. and Donovan, J. E. (1989.) "Value on health and adolescent conventionality: A construct validation of a new measure in Problem-Behavior Theory," Journal of Applied Social Psychology, 19, 841-861.
Donovan, J. E. and Jessor, R. (1985). "Structure of problem behavior in adolescence and young adulthood," Journal of Consulting and Clinical Psychology, 53, 890-904.
DuPont, R. L., Jr. (1985). Getting Tough on Gateway Drugs: A Guide for the Family. (American Psychiatric Press, Washington, DC.)
Golub, A. and Johnson, B. D. (1994). "The shifting importance of alcohol and marijuana as gateway substances among serious drug users," Journal of Studies on Alcohol, 55, 607-614.
Jessor, R. (1987). "Problem-Behavior Theory, psychosocial development, and adolescent problem drinking," British Journal of Addiction, 82, 331-342.
Johnston, L. D., O'Malley, P. M. and Bachman, J. G. (1997). National Survey Results on Drug Use from the Monitoring the Future Study, 1975-1996. Vol. I.Secondary School Students. (U.S. Department of Health and Human Services, National Institute on Drug Abuse, Rockville, MD.)
Kandel, D. B. (1989). Issues of sequencing of adolescent drug use and other problem behaviors. In B. Segal (ed.), Perspectives on Adolescent Drug Use. (Haworth, New York), pp. 55-76.
Kandel, D. B. and Yamaguchi, K. (1993). "From beer to crack: Developmental patterns of drug involvement," American Journal of Public Health, 83, 851-855.
Morgan, J. R, Riley, D. and Chesher, G. B. (1993). Cannabis: Legal reform, medicinal use and harm reduction. In N. Heather, A. Wodak, E. Nadelmann, and P. O'Hare (eds.), Psychoactive Drugs and Harm Reduction. (Whurr, London), pp. 211-229.
National Household Survey on Drug Abuse: Main Findings 1994. (1996). (U.S Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, MD.)
Newcomb, M. D. and Bentler, P. M. (1989). "Substance use and abuse among children and teenagers," American Psychologist, 44, 242-248.
Office of National Drug Control Policy (1997). The National Drug Control Strategy: 1997. (Author, Washington, DC.)
Pape, H. and Hammer, T. (1996). "Sober adolescencePredictor of psychological maladjustment in young adulthood?" Scandinavian Journal of Psychology, 37, 362-377.
Schulenberg, J. E., O'Malley, P. M., Bachman, J. G., Wadsworth, K. N. and Johnston, L. D. (1996) "Getting drunk and growing up: Trajectories of frequent binge drinking during the transition to young adulthood," Journal of Studies on Alcohol, 57, 289-304.
Shedler, J. and Block, J. (1990). "Adolescent drug use and psychological health," American Psychologist, 45, 612-629.
Trebach, A. S. (1987). The Great Drug War. (Macmillan, New York.)
Vaillant, G. E. (1983). The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery. (Harvard University Press, Cambridge, MA.)
Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B. and Castillo, S. (1994). "Health and behavioral consequences of binge drinking in college: A national survey of students at 140 campuses," Journal of the American Medical Association, 272, 1672-1677.
Zimmer, L. and Morgan, J. P. (1997). Marijuana Myths, Marijuana Facts. (The Lindesmith Center, New York.)