When Marijuana Is Used before Cigarettes or Alcohol: Demographic Predictors and Associations with Heavy Use, Cannabis Use Disorder, and Other Drug-related Outcomes

  • Brian J. FairmanEmail author
  • C. Debra Furr-Holden
  • Renee M. Johnson


Recent loosening of state and federal policy restrictions on marijuana, along with changes in social norms regarding marijuana use and decreases in prevalence of other types of substance use, may lead to increases in youth initiating marijuana before other types of substances such as alcohol and tobacco. We investigated predictors and potential consequences of initiating marijuana before other drugs for youth aged 12–21-years in the USA. Nationally representative, cross-sectional survey data from the US National Survey on Drug Use and Health supplied self-reported age of first marijuana, cigarettes, alcohol, other tobacco, and other illegal drug use among 12–21-year-old samples from 2004 to 2014 (n = 275,559). We first examined the degree to which initiating marijuana use first was associated with sex, age, race/ethnicity, and survey year. Then, we examined whether using marijuana first predicted heavy marijuana use, cannabis use disorder (CUD), alcohol use disorder (AUD), nicotine dependence (ND), or lifetime use of other illegal drugs. Among all survey youth (substance users and non-users), the proportion using marijuana first increased from 4.8 to 8.8% from 2004 to 2014. Those using marijuana first (vs. alcohol or cigarettes first) were more likely to be male and older and Black, American Indian/Alaskan Native, multiracial, or Hispanic than White or Asian. Among substance users and adjusting for age of onset and the number of substances used, using marijuana first was associated higher odds of heavy current marijuana use and CUD. In recent years, youth have been increasingly likely to use marijuana as their first drug and sequence of initiation is associated with race/ethnicity, gender, and age. Using marijuana first might increase the chance of heavy use and CUD.


Marijuana Cigarettes Alcohol Dependence Gateway 



Dr. Fairman’s contribution to this work was supported by a grant from the National Institute on Drug Abuse (T32DA007292) and the Intramural Research Program of the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Johnson is supported by a K01DA031738 NIDA grant, and Dr. Furr-Holden is supported by a R01CE002682 grant from the CDC National Center for Injury Prevention and Control.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

The original study procedures were approved by RTI’s Institution Review Board (IRB) for the protection of human subjects. Authors had only access to the publicly available, de-identified data, and thus this research was deemed “not human subjects research” by the Johns Hopkins Bloomberg School of Public Health IRB.

Informed Consent

All survey participants were provided informed consent.

Supplementary material

11121_2018_908_MOESM1_ESM.docx (26 kb)
ESM 1 (DOCX 26 kb)


  1. Agrawal, A., & Lynskey, M. T. (2009). Tobacco and cannabis co-occurrence: Does route of administration matter? Drug and Alcohol Dependence, 99, 240–247. Scholar
  2. Agrawal, A., Budney, A. J., & Lynskey, M. T. (2012). The co-occurring use and misuse of cannabis and tobacco: A review. Addiction, 107, 1221–1233. Scholar
  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC.Google Scholar
  4. Bava, S., & Tapert, S. F. (2010). Adolescent brain development and the risk for alcohol and other drug problems. Neuropsychology Review, 20, 398–413. Scholar
  5. Berg, C. J., Stratton, E., Schauer, G. L., Lewis, M., Wang, Y., Windle, M., & Kegler, M. (2015). Perceived harm, addictiveness, and social acceptability of tobacco products and marijuana among young adults: Marijuana, hookah, and electronic cigarettes win. Substance Use & Misuse, 50, 79–89. Scholar
  6. Boardman, J. D., & Alexander, K. B. (2011). Stress trajectories, health behaviors, and the mental health of black and white young adults. Social Science & Medicine, 72, 1659–1666. Scholar
  7. Caetano, R., & Clark, C. L. (1999). Trends in situational norms and attitudes toward drinking among Whites, Blacks, and Hispanics: 1984–1995. Drug and Alcohol Dependence, 54, 45–56.CrossRefPubMedGoogle Scholar
  8. Caulkins, J. P., & Pacula, R. L. (2006). Marijuana markets: Inferences from reports by the household population. Journal of Drug Issues, 36, 173–200.CrossRefGoogle Scholar
  9. Cox, N. J. (2009). Speaking Stata: Rowwise. Stata Journal, 9, 137.Google Scholar
  10. Dawson, D. A. (1998). Beyond Black, White and Hispanic: Race, ethnic origin and drinking patterns in the United States. Journal of Substance Abuse, 10, 321–339.CrossRefPubMedGoogle Scholar
  11. Degenhardt, L., Chiu, W. T., Conway, K., Dierker, L., Glantz, M., Kalaydjian, A., et al. (2009). Does the ‘gateway’ matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication. Psychological Medicine, 39, 157–167.CrossRefPubMedGoogle Scholar
  12. Degenhardt, L., Dierker, L., Chiu, W. T., Medina-Mora, M. E., Neumark, Y., Sampson, N., et al. (2010). Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys. Drug and Alcohol Dependence, 108, 84–97. Scholar
  13. DiFranza, J. R., Rigotti, N. A., McNeill, A. D., Ockene, J. K., Savageau, J. A., St Cyr, D., & Coleman, M. (2000). Initial symptoms of nicotine dependence in adolescents. Tobacco Control, 9(3), 313–319.
  14. Ellgren, M., Spano, S. M., & Hurd, Y. L. (2007). Adolescent cannabis exposure alters opiate intake and opioid limbic neuronal populations in adult rats. Neuropsychopharmacology, 32, 607–615.CrossRefPubMedGoogle Scholar
  15. Friend, K. B., Lipperman-Kreda, S., & Grube, J. W. (2011). The impact of local US tobacco policies on youth tobacco use: A critical review. Open Journal of Preventive Medicine, 1, 34–43. Scholar
  16. Furr-Holden, C. D. M., Lee, M. H., Milam, A. J., Johnson, R. M., Lee, K.-S., & Ialongo, N. S. (2011). The growth of neighborhood disorder and marijuana use among urban adolescents: A case for policy and environmental interventions. Journal of Studies on Alcohol and Drugs, 72, 371–379.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Gfroerer, J. C., Wu, L.-T., & Penne, M. A. (2002). Initiation of marijuana use: Trends, patterns, and implications. Rockville: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.Google Scholar
  18. Gibbons, F. X., Pomery, E. A., Gerrard, M., Sargent, J. D., Weng, C.-Y., Wills, T. A., et al. (2010). Media as social influence: Racial differences in the effects of peers and media on adolescent alcohol cognitions and consumption. Psychology of Addictive Behaviors, 24, 649.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Golub, A., & Johnson, B. D. (2002). The misuse of the ‘gateway theory’ in US policy on drug abuse control: A secondary analysis of the muddled deduction. The International Journal on Drug Policy, 13, 5–19.CrossRefGoogle Scholar
  20. Green, K. M., Johnson, R. M., Milam, A. J., Furr-Holden, D., Ialongo, N. S., & Reboussin, B. A. (2016). Racial differences and the role of neighborhood in the sequencing of marijuana and tobacco initiation among urban youth. Substance Abuse, 37, 507–510. Scholar
  21. Hilbe, J. M. (2009). Logistic regression models. Boca Raton: CRC Press.CrossRefGoogle Scholar
  22. Hingson, R., & White, A. (2014). New research findings since the 2007 Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking: A review. Journal of Studies on Alcohol and Drugs, 75, 158–169. Scholar
  23. Johnson, R. M., Fairman, B., Gilreath, T., Xuan, Z., Rothman, E. F., Parnham, T., & Furr-Holden, C. D. M. (2015). Past 15-year trends in adolescent marijuana use: Differences by race/ethnicity and sex. Drug and Alcohol Dependence, 155, 8–15. Scholar
  24. Johnson, R. M., Fleming, C. B., Cambron, C., Brighthaupt, S.-C., Dean, L. T., & Guttmannova, K. (2018). Race/ethnicity differences in trends of alcohol, cigarette, and marijuana use among adolescents in Washington state, 2004-2014. Prevention Science (Accepted for Publication). doi not yet assigned.Google Scholar
  25. Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2017). Monitoring the future national survey results on drug use, 1975-2016: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan.Google Scholar
  26. Kandel, E. R., & Kandel, D. B. (2014). A molecular basis for nicotine as a gateway drug. New England Journal of Medicine, 371, 932–943.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Kandel, D. B., & Kandel, E. R. (2015). The gateway hypothesis of substance abuse: Developmental, biological and societal perspectives. Acta Paediatrica, 104, 130–137.CrossRefPubMedGoogle Scholar
  28. Kandel, D. B., & Yamaguchi, K. (1993). From beer to crack: Developmental patterns of drug involvement. American Journal of Public Health, 83, 851–855.CrossRefPubMedPubMedCentralGoogle Scholar
  29. Kennedy, S. M., Patel, R. P., Cheh, P., Hsia, J., & Rolle, I. V. (2016). Tobacco and marijuana initiation among African American and white young adults. Nicotine & Tobacco Research, 18, S57–S64.CrossRefGoogle Scholar
  30. Kirby, T., & Barry, A. E. (2012). Alcohol as a gateway drug: A study of US 12th graders. Journal of School Health, 82, 371–379. Scholar
  31. Landrine, H., Richardson, J. L., Klonoff, E. A., & Flay, B. (1994). Cultural diversity in the predictors of adolescent cigarette smoking: The relative influence of peers. Journal of Behavioral Medicine, 17, 331–346.CrossRefPubMedGoogle Scholar
  32. Morral, A., McCaffrey, D., & Paddock, S. (2002). Reassessing the marijuana gateway effect. Addiction, 97, 1493–1504.CrossRefPubMedGoogle Scholar
  33. Nguyen, T. Q., Ebnesajjad, C., Stuart, E. A., Kennedy, R. D., & Johnson, R. M. (2018). Does marijuana use at ages 16-18 predict initiation of daily cigarette smoking in late adolescence and early adulthood? A propensity score analysis of add health data. Prevention Science.
  34. Novins, D. K., Beals, J., & Mitchell, C. M. (2001). Sequences of substance use among American Indian adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 1168–1174. Scholar
  35. Pacek, L. R., Mauro, P. M., & Martins, S. S. (2015). Perceived risk of regular cannabis use in the United States from 2002 to 2012: Differences by sex, age, and race/ethnicity. Drug and Alcohol Dependence, 149, 232–244. Scholar
  36. Panlilio, L. V., Zanettini, C., Barnes, C., Solinas, M., & Goldberg, S. R. (2013). Prior exposure to THC increases the addictive effects of nicotine in rats. Neuropsychopharmacology, 38, 1198–1208. Scholar
  37. Patton, G. C., Coffey, C., Carlin, J. B., Sawyer, S. M., & Lynskey, M. (2005). Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence. Addiction, 100, 1518–1525.CrossRefPubMedGoogle Scholar
  38. Peters, E. N., Hendricks, P. S., Clark, C. B., Vocci, F. J., & Cropsey, K. L. (2014). Association of race and age with treatment attendance and completion among adult marijuana users in community-based substance abuse treatment. Journal of Addiction Medicine, 8, 143–149.CrossRefPubMedGoogle Scholar
  39. Peterson, P. L., Hawkins, J. D., Abbott, R. D., & Catalano, R. F. (1994). Disentangling the effects of parental drinking, family management, and parental alcohol norms on current drinking by Black and White adolescents. Journal of Research on Adolescence, 4, 203–227. Scholar
  40. Priester, M. A., Browne, T., Iachini, A., Clone, S., DeHart, D., & Seay, K. D. (2016). Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: An integrative literature review. Journal of Substance Abuse Treatment, 61, 47. Scholar
  41. Ramo, D. E., Liu, H., & Prochaska, J. J. (2012). Tobacco and marijuana use among adolescents and young adults: A systematic review of their co-use. Clinical Psychology Review, 32, 105–121. Scholar
  42. Reboussin, B. A., Green, K. M., Milam, A. J., Furr-Holden, D. M., Johnson, R. M., & Ialongo, N. S. (2015). The role of neighborhood in urban Black adolescent marijuana use. Drug and Alcohol Dependence, 154, 69–75. Scholar
  43. Roberts, M. E., Colby, S. M., Lu, B., & Ferketich, A. K. (2016). Understanding tobacco use onset among African Americans. Nicotine & Tobacco Research, 18, S49–S56.CrossRefGoogle Scholar
  44. Sartor, C. E., Agrawal, A., Lynskey, M. T., Duncan, A. E., Grant, J. D., Nelson, E. C., et al. (2013). Cannabis or alcohol first? Differences by ethnicity and in risk for rapid progression to cannabis-related problems in women. Psychological Medicine, 43, 813–823. Scholar
  45. Shiffman, S., Waters, A. J., & Hickcox, M. (2004). The nicotine dependence syndrome scale: A multidimensional measure of nicotine dependence. Nicotine & Tobacco Research, 6, 327–348. Scholar
  46. Shillington, A. M., Woodruff, S. I., Clapp, J. D., Reed, M. B., & Lemus, H. (2012). Self-reported age of onset and telescoping for cigarettes, alcohol, and marijuana: Across eight years of the national longitudinal survey of youth. Journal of Child & Adolescent Substance Abuse, 21, 333–348.CrossRefGoogle Scholar
  47. Sinclair, C. F., Foushee, H. R., Scarinci, I., & Carroll, W. R. (2013). Perceptions of harm to health from cigarettes, blunts, and marijuana among young adult African American men. Journal of Health Care for the Poor and Underserved, 24, 1266–1275. Scholar
  48. Stanley, L. R., Harness, S. D., Swaim, R. C., & Beauvais, F. (2014). Rates of substance use of American Indian students in 8th, 10th, and 12th grades living on or near reservations: Update, 2009-2012. Public Health Reports (Washington, D.C.: 1974), 129, 156–163. Scholar
  49. StataCorp. (2013). Stata statistical software: Release 13. College Station: StataCorp, LP.Google Scholar
  50. Stock, M. L., Gibbons, F. X., Walsh, L. A., & Gerrard, M. (2011). Racial identification, racial discrimination, and substance use vulnerability among African American young adults. Personality and Social Psychology Bulletin, 37, 1349–1361.CrossRefPubMedPubMedCentralGoogle Scholar
  51. Storr, C. L., Chen, C. Y., & Anthony, J. C. (2004). “Unequal opportunity”: Neighbourhood disadvantage and the chance to buy illegal drugs. Journal of Epidemiology and Community Health, 58, 231–237.CrossRefPubMedPubMedCentralGoogle Scholar
  52. Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (No. HSS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration Retrieved from Scholar
  53. Swaim, R. C., Stanley, L. R., & Beauvais, F. (2013). The normative environment for substance use among American Indian students and white students attending schools on or near reservations. The American Journal of Orthopsychiatry, 83, 422–429. Scholar
  54. Timberlake, D. S., Haberstick, B. C., Hopfer, C. J., Bricker, J., Sakai, J. T., Lessem, J. M., & Hewitt, J. K. (2007). Progression from marijuana use to daily smoking and nicotine dependence in a national sample of US adolescents. Drug and Alcohol Dependence, 88, 272–281. Scholar
  55. United States Department of Health and Human Services. (2016). National Survey on Drug Use and Health, 2010-2014. Ann Arbor: Inter-university Consortium for Political and Social Research [distributor] Retrieved from Scholar
  56. Van Etten, M. L., & Anthony, J. C. (2001). Male-female differences in transitions from first drug opportunity to first use: Searching for subgroup variation by age, race, region, and urban status. Journal of Women's Health & Gender-Based Medicine, 10, 797–804.CrossRefGoogle Scholar
  57. Vanyukov, M. M., & Ridenour, T. A. (2012). Common liability to drug addictions: Theory, research, practice. Drug and Alcohol Dependence, 123, S1–S2. Scholar
  58. Vaughn, M., Wallace, J., Perron, B., Copeland, V., & Howard, M. (2008). Does marijuana use serve as a gateway to cigarette use for high-risk African-American youth? The American Journal of Drug and Alcohol Abuse, 34, 782–791. Scholar
  59. Vendetti, J., McRee, B., Miller, M., Christiansen, K., & Herrell, J. (2002). Correlates of pre-treatment drop-out among persons with marijuana dependence. Addiction, 97, 125–134.CrossRefPubMedGoogle Scholar
  60. Wagner, F. A., & Anthony, J. C. (2002a). From first drug use to drug dependence: Developmental periods of risk for dependence upon marijuana, cocaine, and alcohol. Neuropsychopharmacology, 26, 479–488.CrossRefPubMedGoogle Scholar
  61. Wagner, F. A., & Anthony, J. C. (2002b). Into the world of illegal drug use: Exposure opportunity and other mechanisms linking the use of alcohol, tobacco, marijuana, and cocaine. American Journal of Epidemiology, 155, 918.CrossRefPubMedGoogle Scholar
  62. Wells, J. E., & McGee, M. A. (2008). Violations of the usual sequence of drug initiation: Prevalence and associations with the development of dependence in the New Zealand Mental Health Survey. Journal of Studies on Alcohol and Drugs, 69, 789.CrossRefPubMedPubMedCentralGoogle Scholar
  63. White, H. R., Jarrett, N., Valencia, E. Y., Loeber, R., & Wei, E. (2007). Stages and sequences of initiation and regular substance use in a longitudinal cohort of black and white male adolescents. Journal of Studies on Alcohol and Drugs, 68, 173–181.CrossRefPubMedGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018

Authors and Affiliations

  • Brian J. Fairman
    • 1
    Email author
  • C. Debra Furr-Holden
    • 2
  • Renee M. Johnson
    • 3
  1. 1.Health Behavior Branch, Division of Intramural Population Health ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesdaUSA
  2. 2.Department of Epidemiology and BiostatisticsMichigan State UniversityEast LansingUSA
  3. 3.Department of Mental HealthJohn Hopkins Bloomberg School of Public HealthBaltimoreUSA

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