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USE OF MARIJUANA IN THE UNITED STATES Epidemiologic studies provide information on the use of drugs in various subgroups of the population and on the changes in patterns of use over time. The epidemiologic approach is particularly useful in defining patterns of use of marijuana in American society and in describing and analyzing the behavioral and psychosocial antecedents and consequences of that use. One of the more difficult questions is whether particular behavior or effects that are associated with use of a drug are the consequences of that use, or whether attitudes, values, and behavior develop about the use of drugs to constitute factors that may actually lead to the use of drugs. One of the more useful epidemiologic study designs is a cohort study that follows the same individual with repeated observations at regular intervals over time. Such longitudinal studies have the potential for obtaining the most compelling evidence on the antecedents of known patterns of use of marijuana, as well as possible long-term psychosocial and biological outcomes for these individuals. The committee, with the help of consultants, sought answers in the epidemiologic literature to the following five questions: l. What are important patterns of use of marijuana in the American population including special groups? 2. What are the general characteristics of users of marijuana? 3. What is the profile of a user of marijuana on a "daily"* basis? 4. What is known about the antecedents of use of marijuana? 5. How is use of marijuana related to the use of other drugs? The epidemiologic and survey literature have been extensively reviewed and the major longitudinal studies are summarized in a table in Appendix C. Much of our recent knowledge derives from two well-designed major, continuing nationwide monitoring efforts *When placed in quotation marks, "daily" is used as defined by Johnston et al. (l980b), i.e., those individuals using marijuana 20 or more times in the preceding 30 days. 34
35 sponsored by the National Institute on Drug Abuse. One is based on general household population samples, the National Household Surveys. The second is based on populations of high school seniors and is called Monitoring the Future. The National Household Surveys of the general population are conducted on an annual or biannual basis by Response Analysis Corporation and The George Washington University (Fishburne et al., l980). There have been six cross-sectional studies since l97l. The latest one was in the winter of l979-l980, and the next one will be initiated in l982. The subjects are classified as youth (l2-l7), young adults (l8-25), and older adults (26 and older). The questions relate to marijuana and other psychoactive drugs, including inhalants, hallucinogens, cocaine, heroin, stimulants, sedatives, and analgesics. Samples vary from about 3,000 to more than 7,200 new respondents at each survey. These are samples that document patterns of use of drugs in the specified populations at a given time. Monitoring the Future (Johnston et al., l980b) uses a cohort-sequential longitudinal design, in which a new cohort of high school seniors is surveyed each year, and a representative panel selected from that senior class is also followed over time in successive annual or biannual testings. The earliest panel has now been reinterviewed six times. This survey design makes it possible to disentangle antecedents from consequences of use as well as to distinguish changes due to increased age from changes due to cohort peculiarities or historical circumstances. Initiated in 1975 by the Survey Research Center of the University of Michigan, and directed by Lloyd Johnston and Jerald Bachman, the survey involves a question- naire self-administered each year by more than l6,000 high school seniors in l30 public and private schools throughout the United States, and longitudinal mail follow-ups of about 2,000 former students drawn, as panels, from each of the previously participating senior classes (Johnston et al., l979a,b; 1980a,b). Because the National Household Surveys and Monitoring the Future are surveys of persons in households or in high school, they exclude persons most likely to be using drugsâthe transients, those without regular addresses, the school absentees or drop-outs, or those living in institutions or group quarters. These persons constitute a small proportion of the general population, and their exclusion does not significantly bias the epidemiologic estimates reported for the total population (Kandel, l975a). However, data on the very heavy use of drugs may be underrepresented. PATTERNS AND TRENDS OF USE OF MARIJUANA General Population The National Household Surveys found that marijuana was the most commonly used of all the nonlegal psychoactive drugs investigated, including inhalants, hallucinogens, cocaine, heroin, stimulants, sedatives, tranquilizers, and analgesics (Fishburne et al., l980).
36 In l979 more than 50 million persons had tried marijuana at least once in their lives: 68.2 percent of young adults (l8-25), or about 2l million; 30.9 percent of youth (l2-l7), or more than 7 million; and l9.6 percent of older adults (26 and older), or 25 million. The young adult age-group (l8-25 years) has consistently showed the highest rates of current use (used in past month) and ever use (lifetime prevalence), and the older adult groups (26 and older) had the lowest user rates. Male users outnumbered females in all age groups. Between l977 and l979, significant increases in current use and ever use of marijuana were observed among the young adult and older adult cohorts (Figure 2). In l979, in the young adult cohort, the most significant increases in use in the past month were found in males, whites, high school nongraduates, people in the southern United States, and those living in nonmetropolitan areas. In the older adult groups, the most significant recent increase in current use of marijuana was observed in males, whites, college graduates, and people living in the southern states (Miller and Cisin, l980). In the early l960s, illicit drug use in the United States was chiefly a phenomenon of large coastal cities. But since then, rates in other regions of the country and in cities of all sizes have rapidly increased until patterns of use are becoming increasingly comparable for all sectors in the United States. At current levels of use, some experience with marijuana in adolescence is becoming the norm rather than the exception throughout the United States. Other major survey studies have confirmed the findings of the National Household Survey for comparable cohort populations (Gallup Opinion Index, l976; O'Donnell et al., l976). Military Personnel Much attention has recently been focused on what appear to be high rates of use of illicit drugs among military personnel. Studies of drug use among male army veterans of the Vietnam War in l972 showed that marijuana was the most commonly used illicit drug before and after the war (Robins, l974). A random sample of 470 men was selected from the l3,760 enlisted men who returned to the U.S. in September l97l. Of the 45l men who were interviewed, 69 percent had used marijuana while in Vietnam, with 28 percent stating this was their first use of the drug. The lifetime prevalence of use of marijuana was 4l percent prior to Vietnam; 45 percent of the veterans reported using marijuana in the l0 months following return to the United States. Among this group the prevalence of weekly use doubled from l2 percent prior to Vietnam to 25 percent following the war. A worldwide survey of nonmedical use of drugs and alcohol among U.S. active duty military personnel was conducted in l980 under the sponsorship of the U.S. Department of Defense (Burt et al., l980). In an anonymous, self-administered questionnaire given to a repre- sentative sample of more than l6,000 persons, marijuana was found to be the most commonly used illicit drug. Twenty-six percent admitted to having used "marijuana/hashish" within the past 30 days and 35
37 100 80 Â§ 60 1 H 40 20 1960 100 i- - 80 c 01 o 0) a z D O 60 40 20 Percent Ever Used 1967 1972 â¢76 â¢77 1979 YEAR Percent Ever Used I I 1960 1967 1972 â¢76 â¢77 1979 YEAR FIGURE 2 Marijuana: trends in lifetime experience, youth, and young adults. Adapted from J.D. Miller and I.H. Cisin. Highlights from the National Survey on Drug Abuse: l979. Washington, D.C.: U.S. Government Printing Office, l980. Youth Â» l2 to l7 years old; young adults * l8 to 25 years old.
38 percent to having used it in the past l2 months. Five percent of the sample reported use of marijuana daily. When users of drugs were itemized according to military pay classifications, the largest percentage of current use of marijuana was in the lowest ranks of the military. Adolescents and Young Adults Patterns and Trends One of the compelling reasons to focus on adolescence in studying marijuana is the pervasive and increasing use by this age group. As was mentioned earlier, in l980 all geographical regions of the United States and all socioeconomic classes had high and increasingly comparable involvement in use of marijuana. The year l960 has been taken as a baseline year that represents the stable level of overall use of marijuana that had characterized the United States for most of its history. Figure 2 shows the trends for use of marijuana from l960 through l979, revealing the sharp upward climb of use of marijuana starting in l967. The dramatic rise in use of marijuana by adolescents has recently slowed, and the lifetime prevalence rates (ever use) of marijuana have remained at approximately 60 percent of all high school seniors for the years l979 and l980 (Figure 3). To put it another way, in l979 over 2.5 million high school seniors had tried or were users of marijuana. (This figure is derived from calculations based on l979 Census Bureau data that give a figure of 4,276,000 for number of l8-year-olds in the population. The committee is aware that all l8-year-olds are not high school seniors and that such a calculation may underreport the numbers of users of marijuana, particularly heavy users who have been shown to be more likely to have dropped out of school. Similar calculations have been attempted throughout this chapter.) The use of other types of drugs by young people also increased beginning in l967 (Miller and Cisin, l980). Figure 4 gives the most recent nationwide figures for use of ll types of drugs among American high school seniors (average age l8 years). With the exception of negligible use of heroin, the figures for use of all other drugs are substantial. Increases in patterns of use have not been as dramatic for other drugs (except for recent cocaine increases) as they have been for marijuana. Use of marijuana, tobacco, and alcohol far outstrips that of all other drugs. In l980 the lifetime prevalence (ever use) for these substances by high school seniors was marijuanaâ60 percent, tobaccoâ7l percent, and alcoholâ93 percent. Of even greater interest are the percentages of high school seniors who use the ll types of drugs "daily." In l980 marijuana was used "daily" by 9.l percent (about 390,000), alcohol by 6.0 percent (about 256,000), and tobacco cigarettes by 2l.3 percent (about 900,000) of high school seniors (Johnston et al., l980a). No other substance was used that frequently by as many as l percent of the
39 BE O 70 r- 60 50 LU IA 8 40 (Â£ I u. 30 O H LU U oe (D Â°- 20 10 | J Percent ever used IJJJ&H Percent who used in last 12 months ] Percent who used in last 30 days â¢ Percent who used daily in last 30 days 59.2 60.4 60.3 56.4 52.8 47.3 Class of 1975 Class of 1976 Class of 1977 Class of 1978 Class of 1979 Class of 1980 FIGURE 3 Trends in prevalence of marijuana use by high school seniors, l975-l980 (in school). Adapted from L.D. Johnson, J.G. Bachman, and P.M. O'Malley, Highlights from Student Drug Use in America, l975-l980. DHHS Publication No. (ADM) 8l-l066. Washington, D.C.: U.S. Government Printing Office, l980a.
40 100 i- o 8 O 1 111 o 80 60 40 20 KEY 93% UJ o H| LLJ '5 -I C< Used Drug, but Not in Past Year, Used in Past Year, Not in Past Month Used in Past Month (30 Day Prevalence) c 1 B v> 4) cl C ra 2 03 N I "ro * 'a O 10 if 1 CO Vt 1 1 â¢p 1 '5 cr c Is u If O H 51 tO Vi ^E c Â«j o io c -e * I 1 â¢C ro ~; ra Oi < NOTE: The bracket near the top of a bar indicates the lower and upper limits of the 95% confidence interval. FIGURE 4 Prevalence and recency of use. Eleven types of drugs, class of l980. SOURCE: Johnson, L.D., Bachman, J.G., and O'Malley, P.M. Highlights from Student Drug Use in America, l975-l980. DHHS Publication No. (ADM) 8l-l066. Washington, D.C.: U.S. Government Printing Office, l980a. students. These figures show that legal (for adults) drugs are used much more frequently than illegal ones. Reports of illegal use of drugs show that experimentation with marijuana has, by far, the highest prevalence. It should be noted, also, that "daily" use of marijuana (9 percent) among high school seniors is now more prevalent than "daily" drinking (6 percent) of alcoholic beverages. In l980, for the first time since l975, when the Monitoring the Future data collection began among high school seniors, the percentage of "daily" users of marijuana among seniors in high school declined significantly from l0.3 percent in l979 to 9.l percent in l980 (Figure 3), and there was a leveling of lifetime prevalence at approximately 60 percent. Furthermore, the proportion of current users among those who ever used marijuana also showed a statistically significant decline in l980 as compared to l979, from 60 percent to 56 percent. However, "daily" users may be increasingly underrepre-
4l sented in recent senior high school classes due to absenteeism and drop-out associated with increasingly earlier and extensive involvement in use of marijuana. The extent to which long-term "daily" users have dropped out of school by the senior year of high school cannot be ascertained from monitoring the future. Kandel (l975a) found that absentees differed from students attending school regularly. Fifty-six percent of absentees reported use of marijuana as compared to 38 percent of in-class students. Studies that document the patterns of marijuana use in school drop-outs are needed. Correlates of Use Overall levels of use of marijuana have been shown to correlate with patterns of use of the drug. l. Increased prevalance is associated with younger age of initiation into use of marijuana. As successive cohorts of high school seniors have shown increasingly higher levels of experience with marijuana from l975 through 1980, these cohorts also report increasingly earlier ages at first use of marijuana. For example, in the senior class of l980, which had a lifetime prevalence of 60 percent by senior year, 25 percent of those using marijuana had begun in the eighth grade (average age l4) or below. In l975 when lifetime prevalence was 47 percent, l5.3 percent of marijuana users had begun in eighth grade or below. It is of some interest to compare reported age of use of marijuana by grade for the senior class of l980 (lifetime prevalence 60 percent) and alcohol (lifetime prevalence 93.2 percent). The more prevalent drug, alcohol, is used at earlier ages than marijuana. Thirty-three percent of alcohol users had started at eighth grade as compared to 2l.5 percent of marijuana users (Johnston et al., l980a). 2. Earlier onset of use of any drug is associated with greater involvement in use of all other drugs. The earlier the introduction to legal (for adults) drugs, the greater the probability that the adolescent will also experiment with illicit drugs. For example, among young adults l8-25 years of age surveyed from the general population in l979-l980, the proportion who had experimented with any illicit drug other than marijuana ranged from 87 percent among those who reported having first tried alcohol or marijuana at ages l3 or l4, to 47 percent among those who first tried these drugs at ages l5-l7, and 5 percent among those who first experimented at age l8 or over (Rittenhouse, l980). The finding that the earlier the experimentation with marijuana, the greater the intensity of involvement and the greater the likelihood of using more serious drugs has been confirmed in many studies (e.g.. Miller and Cisin, l980; Johnston et al., l980a; Kandel et al., l98l). 3. Greater overall prevalence of use of marijuana is associated with greater persistence of use of marijuana into later years of adult life. The current prevalence rates for use of marijuana by persons in their mid-30s are increasing (Cisin et al., l978). Many
42 studies have not sampled this population in the belief that use of marijuana drops off sharply in the mid-20s. Among males, the prevalence rate for use of marijuana in the past month for over-26-year olds went from 4 percent in l977 to 9 percent in l979. It will be exceedingly important to monitor the trends in all older adult age groups. Marijuana and the Use of Other Drugs One of the key questions asked over the years is, does marijuana lead to the use of other drugs. In any population, the use of various drugs appears interrelated and users of any type of drug, whether legal or illegal, are much more likely to use other types of drugs than nonusers. For example, young people who smoke tobacco are also much more likely to have used alcohol or marijuana than nonsmokers (Fishburne et al., l980). Similarly, there is a strong association between the use of marijuana and of other illicit drugs. Young people who use marijuana are more likely to be consuming other substances, such as alcohol and tobacco, as well as other illicit drugs (Johnston et al., l980b). The association increases with extent of marijuana involvement and is especially striking among those young people who use marijuana on a "daily" basis, as will be discussed below. Results from the National Household Surveys and from samples of high school seniors had indicated that the ratio of rates of use of illicit drugs other than marijuana to use of marijuana declined through l979 (Kandel, l980; Miller and Cisin, l980). In l980, however, the ratio started to rise again. Thus, in l980, 65 percent of marijuana users among the high school seniors had also used other illicit drugs as compared to 6l percent in l979 (Johnston et al., 1980a). "Daily" Users in High School Because any health risks resulting from the use of marijuana would be most likely to appear first in chronic users of the drug, the young persons who are chronic and heavy users are of special interest. The committee reports in some detail the findings on this group. The ranks of "daily" users are large. In l980 they represented more than 9 percent of high school seniors or over 390,000 l8-year-olds in the United States. One out of ll seniors fitted the definition of "daily" users (20 or more occasions of reported use within the preceding 30 days). Collection of systematic data on such users began in l975 with the annual monitoring of in-school high school seniors. There are many gaps in our knowledge about this group, but sufficient data have been accumulated that it is now possible to describe many of the behavioral attributes of the "daily" users. Most of these data come from Monitoring the Future. Some of the findings recently reported by Johnston (l980, l98l) and Bachman et al. (l98l) are as follows:
43 Demographic Findings Rates of "daily" use do not vary among regions of the country, but "daily" use shows a strong positive relationship to the size of the community and is more prevalent in urban areas. Males are "daily" users at almost double the rate of females (l3 percent versus 7 percent). "Daily" use among white students is double that for blacks (ll percent versus 5 percent). "Daily" use is spread evenly across socioeconomic levels as defined in terms of parents' education. "Daily" use is only slightly higher among those from homes in which one or both parents are absent. Academic Performance and Goals "Daily" use is associated with poor school achievement. Among non-college-bound seniors the rate of "daily" use is almost double that found among the college-bound (l3 percent versus 7 percent). There are strong and positive correlations of "daily" use and cutting classes, school absences, and truancy. Much of "daily" use takes place within the school setting. A statewide study of seventh through twelfth grade pupils in New York, conducted in l978 by the New York State Drug Abuse Commission, found that 50 percent of those using marijuana within the last 6 months had been intoxicated one or more times while in class (Johnson and Uppal, l980). In contrast, alcohol tends to be used most frequently after school and on weekends. Religious Commitment A commitment to religion and self-ratings of strong belief in law-abiding behavior are associated with lower than average rates of "daily" use. Dating and Social Life Dating and social life show strong relationships with "daily" use of marijuana. Those who spend more time on dates have the highest rates of "daily" use of marijuana. Among those students who go out 6 or 7 nights a week and are practically never at home, 34 percent are "daily" marijuana users. Use of Other Drugs "Daily" marijuana users are much more likely than their peers to be extensive users of other drugs. Thus, of seniors in the class of l979, 27 percent of "daily" users of marijuana drank alcohol as frequently, versus 7 percent for the age-group as a whole; and 59
44 percent of "daily" users of marijuana smoked cigarettes as frequently versus 25 percent for the group as a whole (Johnston et al., l980b). With respect to use of other illicit drugs, the rates for "daily" users of marijuana generally run five to seven times the average for the age group as a whole; 47 percent of "daily" users are current* users of amphetamines; 3l percent of cocaine; and their current usage figures run from l5 to l7 percent for barbiturates, for lysergic acid diethylamide (LSD), for phencyclidine (PCP), for methaqualone, and for tranquilizers. Since nearly two-thirds of daily marijuana users (64 percent) are current users of hashish, they have substantial exposure to a high-potency form of marijuana. We also know from data on age at first use that many of these "daily" marijuana users began their use of cigarettes, alcohol, and various other illicit drugs at quite an early age. To illustrate, by the end of eighth grade 40 percent of them had smoked cigarettes "daily" and 50 percent had taken their first drink. Just about half of them (48 percent) first tried marijuana by the eighth grade, and most of the remainder (another 30 percent) started in ninth grade. These are very early ages of initiation for all three drugs. Similarly, these youngsters tend to take up the other illicit drugs at an earlier than average ageâthough most of that use still is initiated after ninth grade. "Daily" use tends to persist longer into adult life than anticipated. In l979, 4 years after graduation from high school, 5l percent of marijuana users of the senior class of l975 were still "daily" users and an additional 34 percent were current although not "daily" users (Johnston, l980). "Daily" Users After High School Using a national sample of l9- to 22-year-olds derived from the follow-up surveys of Monitoring the Future, Johnston (l98l) reported on "daily" use of marijuana after high school. (These findings are reproduced nearly verbatim below.) College Student Status Student status after high school correlates negatively with "daily" use; that is, full-time college students have the lowest rate (8 percent), part-time students the next lowest (l0 percent), and nonstudents the highest rate (l3 percent). However, although full-time students have a lower than average rate of "daily" use, they showed the greatest increase after high school (up from 4.5 to 8.3 percent): they simply started from a very low level and in a sense were "catching up." *A current user is one who has used the drug in the thirty days preceding the surveys.
45 Living Status Young people who are living away from home have a higher proportion of "daily" use than those still living with their parents (l2 percent versus l0 percent), probably reflecting the result of reduced social control by parents. Those who remained living with their parents (nearly half) showed relatively little increase in use (up l.3 percent), while those who moved out increased their daily use rate substantially (up 3.9 percent). Marital Status Those who are single are almost twice as likely to be "daily" users as those who are married (ll.4 percent versus 6.6 percent), and those without children are somewhat more likely to use marijuana than those with children (ll percent versus 8 percent). It appears that these role responsibilities have a dampening effect on use. In the face of an overall 2.6 percent increase in "daily" prevalence after high school for the whole sample, those who were married showed virtually no increase (up 0.2 percent) and those with children actually had a decline in use (down l.5 percent). Type of dwelling "Daily" use is highest for those living in a rented room (l4 percent) or apartment (l2 percent), and lowest for those living in a college dorm (8 percent). Obviously one's dwelling arrangement is highly correlated with his or her major activity after high school, as these differences reflect. Employment Employment status is unrelated to "daily" use. For those in military service, "daily" use dropped slightly after high school (from l3.4 percent to l2.4 percent). The activity group with by far the lowest "daily" use rate are the full-time homemakers (4 percent), which certainly occurs, in part, because they nearly all are female, married, and in many cases have young children. Reasons for Using or Abstaining Reasons for "Daily" Use of Marijuana What reasons do "daily" users give for their use of marijuana? They tend to use marijuana to produce an intoxicated feeling, to cope psychologically with feelings of distress, to augment the effects of other drugs, and to participate in drug-using friendships. On a
46 checklist of l3 possible reasons, nearly all of the seniors who were "daily" users checked "to feel good or get high" (94 percent) and "to have a good time with my friends" (79 percent). Two-thirds said they used it to relax (67 percent) and nearly half said they used it to relieve boredom (45 percent). Roughly a quarter of the "daily" users checked each of the following: "to get away from my problems" (27 percent), "because of anger or frustration" (23 percent), and "to get through the day" (22 percent). These psychological coping motives in particular seem to distinguish the "daily" users from the less frequent users. A fairly high proportion (30 percent) also said that they used marijuana to increase the effects of other drugs, while only l0 percent of the other current users gave this reason. Only ll percent of the "daily" users, or l percent of the total sample, stated that they used it because they felt "hooked" or had to have it. All of these responses for seniors were closely replicated among the "daily" users in the l9- to 22-year-old sample (Johnston, l98l). Nearly all "daily" users (over 85 percent), whether in high school or past high school, say (l) that most or all of their friends smoke marijuana, (2) that most or all of their friends drink alcohol, (3) that more than a few of their friends get drunk every week, (4) that more than a few of their friends smoke cigarettes, and (5) that at least a few of their friends use a number of other illicit drugs. This degree of immersion in a drug-using friendship circle contrasts sharply to what we observe for their peers, even those who are current but less frequent users of marijuana. Clearly the social supports and the social pressures are there, both during and after high school, for the "daily" user to continue his or her habit. Reasons for Quitting and Abstaining A number of users of marijuana stop using the drug (Johnston, l98l). Among students (in the classes of l978 through l980 combined), those who have used marijuana 40 or more times but have stopped by their senior year give as their most commonly mentioned reason on a comprehensive list of l7 reasons that "they don't feel like getting high" (56 percent mentioned). Also frequently mentioned, however, are concerns about possible physical effects (4l percent); concern about possible psychological effects (38 percent); and, more specifically, concern about loss of energy or ambition (4l percent). These reasons also ranked high among those young people who smoked less than 40 times before they stopped, as did two additional reasonsâconcern about parental disapproval and finding that use of marijuana was not intrinsically enjoyable. Concern about possible health effects appears to play a role in young people's giving up the drug and is mentioned considerably more often among quitters now than in l976. Concern about physical health increased substantially between l976 and l980 among all high school seniors, from 35 percent to 57 percent, while concern about psychological damage went from 34 percent to 53 percent. A similar analysis of the reasons given for abstaining by the minority (about
47 40 percent) of seniors who have never tried marijuana reveals concern about physical (7l percent) and psychological (68 percent) consequences, which are mentioned far more often than any other type of reason. Social or ideological constraints or disinterest in getting high are infrequently mentioned. There also has been a significant increase in health concerns among the abstaining segment since l976, though not as large as among quitters. In summary, many "daily" users themselves see some negative consequences of their habit, and there perhaps are some consequences of which they are unaware. The fact that the "daily" smoking of marijuana is proving to be more enduring and stable than many may have thought increases the probability of cumulative, long-term effects. The fact that so many young people are becoming "daily" users now puts a substantial number of people at risk of whatever the long-term consequences may prove to be. Sequence of Drug Use Regardless of the age of onset, there is a predictable sequence in the patterns of initiation into the use of available drugs. Independent longitudinal studies have confirmed and identified a stable sequence of drug use (Hamburg et al., l975; Kandel, l975b; Kandel and Faust, l975). The legal drugs for adults, such as alcohol and tobacco, are an early, integral, and crucial part of the sequence. Their use precedes the use of all illicit drugs. At least four distinct successive stages of adolescent involvement with drugs can be identified: (l) use of beer or wine, (2) use of tobacco cigarettes or hard liquor, (3) use of marijuana, and (4) use of other illicit drugs (Kandel, l975b). A fifth stage, problem drinking, may take place between marijuana and other illicit drugs (Jessor et al., l980). Adolescents rarely proceed from beer and wine to illicit drugs without use of either hard liquor or tobacco cigarettes as an intermediate step. Furthermore, there is an additive effect such that the highest proportion of adolescents who move to marijuana are those who have experience with both hard liquor and tobacco. For example, among l2- to l7-year-olds in the general population, the proportion who have ever experimented with marijuana is 8l percent among current tobacco cigarette smokers as compared to 24 percent among nonsmokers (Fishburne et al., l980). However, position on a particular point in the sequence does not indicate that the young person will necessarily progress to other drugs higher up in the sequence. Participation in each stage is a necessary but not sufficient condition for participation in a later stage. There is no evidence to support the belief that the use of one drug will inevitably lead to use of any other drug. In other words, persons at the top of the ladder of use of drugs typically will have used all substances at lower levels, including marijuana. However, those at lower rungs may stay there and not move to higher rungs of the ladder. For example, data from the National Household Surveys (Fishburne et al., l980) indicate that of those l8-25 years old who have tried
48 marijuana, almost all are users of tobacco or alcohol; however, only slightly more than one-fourth of this l8- to 25-year-old population report having gone on to try any illegal drug other than marijuana. Of those who try other illegal drugs, only a very small percentage report being current users (Fishburne et al., l980). Although it is of great interest, relatively little is known about the factors that determine which persons will choose to go through the sequence of drug use or the rapidity with which they will do so. Existing research gives us some clues that users of illicit drugs possess some distinguishing features. There are four clusters of variablesâparental influences, peer influences, adolescent involvement in deviant behaviors, and adolescent beliefs and valuesâthat assume differential importance for predicting involvement at each stage of drug behavior (Kandel et al., l978a,b). Involvement with drugs legal for adults is the earliest level of drug use. Adolescents who start to drink are exposed to peers and parents who drink, suggesting that these youths learn drinking patterns from their parents. Adolescents who have engaged in a number of delinquent or deviant activities, and who seek high levels of sociability with their peers are likely to become involved with alcohol. Similar patterns are found with tobacco smoking, also one of the earliest drugs to be tried. The use of marijuana follows that of alcohol and tobacco. It is preceded by acceptance of a cluster of beliefs and values that often reflect disavowal of many standards upheld by adults. Involvement in a marijuana-using peer environment strongly predisposes to its use and is the best predictor (Becker, l953; Goode, l970). Participation in minor forms of deviant behaviors, such as those that also precede the use of hard liquor, is also an important precursor. Antecedents of Adolescent Use of Marijuana When use of marijuana first came under research scrutiny in the late l960s, very few youths had experimented with illicit drugs. Much was made of the deviant status of use of marijuana and of the counter- cultural and rebellious meaning that came to be attached to using the drug (Suchman, l968). Yet even today, when over 60 percent of all high school seniors have used marijuana, those youths who use marijuana are quite different from nonusers. The marijuana users in l979 show the same patterns of disaffection from major institutions that characterized the users in l967. The most recent data show that marijuana users perform more poorly in school, are less religious, have performed more delinquent acts, are in trouble with the law, have more traffic accidents, and use more illicit drugs than nonusers. Those persons who also use several illicit drugs show the highest involvement in deviant behaviors. There is a linear relationship with degree of involvement with illicit drugs, such that persons using marijuana exclusively are only quantitatively different from those who have also used harder drugs (Johnston et al., l980b).
49 In two cross-sectional national samples of high school students, surveyed in l974 and l978, Jessor et al. have found that not only are the patterns of association between use of marijuana and deviant characteristics similar in both surveys, but also that the strength of the associations, as reflected in the sizes of the correlation coefficients, are almost identical. The very same conclusions derive from analyses based on five successive cohorts of high school seniors, sampled at yearly intervals in Monitoring the Future (Bachman et al., l98l). Longitudinal studies of students aged l2-2l have done much to extend our understanding of the precursors of using various forms of drugs. Studies have been reviewed in detail by Kandel (l978a,b; l980a; also see Appendix C) and document that many of the factors found to be associated with use of drugs at one point in time, such as low academic performance, crime, low self-esteem, depressive mood, rebelliousness, and other personality characteristics, precede the use of drugs (see in particular Mellinger et al., l976; Jessor and Jessor, l977; Johnston et al., l978; Kandel, l978a; Kandel et al., l978b,c; Kaplan and Pokorny, l978; Smith and Fogg, l978; Wingard et al., l979; Kaplan, l980). Some of the predictive factors can be identified in childhood, such as aggressiveness with or without association with shyness (Kellam et al., l980, in press) and rebelliousness (Smith and Fogg, l978). Other longitudinal studies also document that many of the factors found to be associated with use of drugs at one point in time, such as low academic performance, delinquency, low self-esteem, and depressive mood actually precede the use of drugs (O'Malley, l975; Mellinger et al., l976; Jessor and Jessor, l977; Johnston et al., l978; Kandel et al., l978a; Kaplan and Pokorny, l978; Wingard et al., l979; Kaplan, l980). One study shows not only that certain behaviors predict use of marijuana, but also that drugs may aggravate or exaggerate certain behaviors. A cohort of high school students was followed at annual intervals throughout the four years of high school (Jessor and Jessor, l977). During this time annual scores for various attributes were charted in four groups of students distinguished by differing drug histories: veteran users, who used drugs pre-high school; early initiates, who began relatively early in their high school career, i.e., between the first and second year of testing; late initiates, who began relatively late, i.e., between the second and the third year; and nonusers, who had not started to use marijuana at the last testing in the senior year of high school (Jessor and Jessor, l977, l978). These four groups of students differed on measures, such as general deviant behavior (a l2-item scale measuring frequency of involvement in stealing, fighting, property destruction, truancy, or other delinquent activities in the last year) or value on academic achievement (a five-item scale, measuring the value placed on the attainment of success in school work), at the beginning of the study. Scores predicted if and when students initiated use of marijuana. Those students already involved in use of drugs before high school scored highest on deviance and lowest on achievement motivation at
50 initial testing and throughout subsequent retests. The scores of all groups of users converged over time so that all three groups increased in deviance scores and decreased in their achievement orientation over the four years. The sharpest changes in scores occurred in the year preceding the drug use. Peer Influences The most consistent and reproducible finding in drug research is the strong relationship between an individual's drug behavior and the concurrent use of drugs by his friends. The relationship is stronger when based on adolescents' perceptions of the friends' behavior than on the friends' self-reports (Goode, l970; Johnson, l973; Kandel, l973; Goldstein, l975; O'Donnell et al., l976; Brook et al., l977; Jessor and Jessor, l977; Kandel et al., l978a; Orcutt, l978; Smart et al., l978; Huba et al., l979). On no other characteristic except age and sex is the similarity within adolescent friendship pairs as high as it is for use of marijuana (Kandel, l978c). Such similarity results not only from socialization, the influence of one friend on the other, but also from a process of interpersonal selection (assortive pairing), in which adolescents with similar values and behavior seek each other out as friends. Longitudinal data on the formation and dissolution of friendships indicate that selection and socialization contribute about equally to the similarity in values and behaviors (Kandel, 1978d). Available data on sex differences in peer influence indicate that females are more susceptible than males to such influence (Jessor et al., l973; Margulies et al., l977). Susceptibility to peer influence is related to involvement in peer-related activities, e.g., dating or getting together with friends, and to degree of attachment to and reliance on peers rather than parents (Jessor and Jessor, l978; Kandel et al., l978a; Brook et al., l980). Contact with other users increases the likelihood that the individual will have increased opportunities to get the drug. Peer-mediated approaches have been shown to be an effective vehicle for interventions to prevent smoking of tobacco in adolescents (Evans, l977; McAlister, l979). The powerful role of peer influence on the use of marijuana would seem to suggest that it would be also useful for preventive marijuana programs. SUMMARY There has been a steep rise in the use of marijuana and other illicit drugs in the past decade. So far it is primarily a youth phenomenon. Since l97l there has been at least a doubling of lifetime experience with marijuana in every cohort in the l2- to 24-year age group. Of all psychoactive drugs investigated (including inhalants, hallucino- gens, cocaine, heroin, stimulants, sedatives, and tranquilizers), marijuana is by far the most commonly used illicit drug. Legal drugs for adults, such as alcohol and tobacco, are the most widely used of
5l all drugs among adolescents. Although substantially more students have ever used alcohol in their lifetime than have ever used marijuana, more high school seniors use marijuana on a "daily" basis (9 percent) than use alcohol that frequently (6 percent). "Daily" users report the use of marijuana in school, whereas daily use of alcohol tends to occur after school and on weekends. Some trends in use of marijuana are apparent. The continuing dramatic rise in the use of marijuana has recently slowed. It is too early to tell whether this decrease will continue or is merely a pause in the rise. The overall prevalence of use of marijuana has remained at approximately 60 percent of high school seniors for the years l978, l979, and l980. Between l975 and l978 there was an almost twofold increase in "daily" use of marijuana from 6 percent in l975 to a peak rate of ll percent in l978. In l980 the "daily" use rate of high school seniors dropped by l.2 percentage points, or more than l0 percent. This may signal a reversal of the upward trend in "daily" use unless higher absenteeism and school drop-out of daily users are significant factors in the decline. Multiple sources suggest that out-of-school age mates are heavier users than those in school. Other trends have not slowed. There was a continuing rise in l980 of the proportion of high school seniors who during the year had used some illicit drug other than marijuana, from 28 percent in l979 to 30 percent in l980. Throughout the l970s, as a correlate of continuing rise in prevalence rates, there was a trend toward younger ages of first use of all of these drugs. For marijuana this age trend continues but has slowed somewhat. In l979, 23 percent of seniors who had used marijuana started their use in the eighth grade or below as compared to 25 percent in l980. "Daily" use of marijuana in high school and in early adult life is very high and merits special attention. Drawing on data from Monitoring the Future, characteristics of "daily" users were described. For high school seniors the rate of "daily" marijuana use in l980 was 9.l percent. Such users have very high involvement with other drugs and begin their use of drugs at very early ages. "Daily" users are predominantly urban although rates do not vary by geographi- cal regions of the country, whereas use among white students is double that for blacks. "Daily" use is only slightly higher in disrupted or single parent homes than in nuclear families, and use is associated with poor school achievement, absenteeism, and dropout. Non-college- bound students are twice as likely to be "daily" users as were students planning to attend college. Religious commitment and self-ratings of strong belief in law-abiding behavior are associated with lower "daily" use rates. "Daily" users are involved in more automobile accidents and delinquency. Post-high school "daily" user rates are lowest among full-time college students and those living in a college dormitory. "Daily" use among non-college students was not related to joblessness, employment, or military service. Single persons are twice as likely as married persons to be "daily" users. Among the married, those with children had very low rates of "daily" use. The "daily" use
52 habit has a remarkable stability. By 4 years after high school, 85 percent of "daily" using seniors in the class of l975 were still using marijuana, with 5l percent of them continuing to be "daily" users. In these studies, students report reasons for using marijuana: to have a good time with friends, to get "high," to relieve boredom, to enhance the effects of other drugs, and to cope with stress. "Daily" users are deeply immersed in a drug-using circle of friends. Some "daily" users have discontinued their habit. Reasons given for stopping use of marijuana are loss of interest in getting "high," concern about harmful physical or psychological effects, and concern about their loss of energy or ambition. More is known about the antecedents of using marijuana than is known about the consequences of using marijuana (to be discussed further in the chapters that follow). Longitudinal studies have established that use of marijuana is preceded by acceptance of a cluster of beliefs and values that are favorable to use of marijuana and also by the adoption of deviant behaviors. The deviant psycho- social attributes of marijuana users that were described almost a decade ago, when use of marijuana was a rare event, are just as characteristic of marijuana users today, when 60 percent of all high school seniors report some experience with the use of marijuana. Daily users show the extremes of these deviant behaviors but less deeply involved users also exhibit some deviancy. Friendship patterns and peer influence play a uniquely powerful role in determining youthful marijuana use. Negative parental relationships do not appear to be associated as an antecedent to use of marijuana. RECOMMENDATIONS FOR RESEARCH Additional research needed includes (l) epidemiologic studies on patterns of use of drugs among young adolescents, including those who leave school, (2) longitudinal studies to investigate the antecedents and consequences of use of marijuana, and (3) studies of the effects of marijuana in combination with use of other drugs. Because samples of high school seniors exclude youths most at risk for high marijuana involvement, namely adolescents not regularly attending the high school, additional cohort-sequential epidemiologic surveys beginning with prepubertal children are needed in order to follow development and behavior from early in life. An all-conclusive approach would be both a prospective (concurrent) cohort study and a retrospective case-control study of possible outcomes of and risk factors for marijuana use (this recommendation is described in detail in Chapter 6). "Daily" users have been understudied and may have the most severe risk in terms of loss of learning potential, biological risk, and psychosocial handicap. Studies should be undertaken to predict who among the large numbers of young people who try marijuana are at risk of becoming "daily" users.
53 Research on the factors involved in cessation of the use of marijuana should also be carried out. Tobacco smoking is declining among youth (National Institute of Education, l979) . The reasons for this decline could be applicable to marijuana use and should be sought. Studies should be undertaken to learn how peer influence can be reliably used to moderate or prevent marijuana use in young adolescents. Properly planned longitudinal cohort studies should be conducted on both the behavioral and physiological antecedents and consequences of the use of marijuana. Detailed and continuing medical and psychosocial data are needed on the life careers of American adults who use marijuana "daily." Retrospective studies of middle-aged and elderly persons who have a history of chronic heavy use of marijuana would be systematically studied for medical and psychosocial attributes and for effects on job performance. These are especially needed for urban industrialized populations. Little is known about the consequences of using marijuana in combination with other drugs. Inasmuch as the rates of use of other drugs are so high, this is of great salience. Interdisciplinary and collaborative efforts are crucial if the complexities of multiple drugs and intercorrelated behaviors are to be disentangled. REFERENCES Bachman, J.G., Johnston, L.D., and O'Malley, P.M. Smoking, drinking, and drug use among American high school students: Correlates and trends, l975-l979. Am. J. Public Health 7l:59-69, l98l. Becker, S. Becoming a marihuana user. Am. J. Sociol. 54:235-242, l953. Brook, J.S., Lukoff, I.F., and Whiteman, M. Peer, family, and personality domains as related to adolescents' drug behavior. Psychol. Rep. 4l:l095-l02, l977. Brook, J.S., Lukoff, I.F. and Whiteman, M. Initiation into adolescent marihuana use. J. Gen. Psychol. l37:l33-l42, l980. Burt, M.R., Biegal, M.M., Carnes, Y., and Farley, B.C. Worldwide Survey of Nonmedical Drug Use and Alcohol Use Among Military Personnel: l980. Bethesda, Md.: Burt Associates, Inc., l980. Cisin, I., Miller, J.D., and Harrell, A. Highlights from the National Survey on Drug Abuse; l977. Washington, D.C.: U.S. Government Printing Office, l978. Evans, R.I., Hansen, W.B., and Mittlemark, M.B. Increasing the validity of self-reports of behavior in smoking in children investigation. J. Appl. Psychol. 62:52l-523, l977. Fishburne, P.M., Abelson, H.I., and Cisin, I. National Survey on Drug Abuse: Main Findings: l979. DHHS Publication No. (ADM) 80-976. WAshington, D.C.: U.S. Government Printing Office, l980. Gallup Opinion Index, pp. l-ll. Report No. l43. Marijuana in America, l976. Goldstein, J.W. Assessing the interpersonal determinants of adolescent drug use, pp. 47-52. In Lettieri, D.J. (ed.)
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