Q&A

Is cannabis a “gateway drug”?

Context
In the context of cannabis legalization, public health practitioners may encounter the question of
whether cannabis is a “gateway drug” (i.e., its use leads to the use of other substances) in their work in
school health and other settings. This Q&A is intended to provide practitioners with current evidence
and to enable public health practice. It is beyond the scope of this Q&A to address the health effects of
cannabis for youth overall.

Key Messages
 The gateway hypothesis overall has not been proven, and specifically, there is no conclusive
evidence that cannabis use causally leads to the use of other substances.

 Most people do not begin using other drugs following the use of cannabis; however, frequent or
early use of cannabis may also be associated with subsequent use of other drugs.

 It is possible that people who ultimately use other substances may start with substances that
are more easily available such as cannabis, tobacco or alcohol.

 Initial and subsequent substance use may involve complex relationships with other factors, such
as adverse childhood experiences or social influences.

What is the gateway hypothesis?

 Kandel and Faust published original work in the 1970’s that described a sequence in substance
use initiation in a longitudinal study of secondary school students in New York State, progressing
from alcohol use to tobacco use, followed by cannabis and subsequently other substance use.1

 The authors initially cautioned that this finding should not be considered causal, but later
suggested that some substances are a “gateway” to others.1 This became known as the
“gateway hypothesis”.1

 Overall, there remain important gaps in understanding patterns of how the use of some
substances may occur before others.2

Q&A: Is cannabis a “gateway drug”? 1

What is the evidence on cannabis as a gateway drug?
Animal studies
 Overall, animal studies are mixed regarding evidence of a gateway effect.3

Epidemiology
 Observational studies may demonstrate associations, but these do not necessarily reflect causal
relationships.

 Epidemiologic studies have observed a similar sequencing pattern of substance use initiation
among youth cohorts, for example in the United States and New Zealand.1,4 Among people who
ever used cannabis in the United States, 44.7% had ever used another illicit drug.5

 Regarding initiation of use, use before age 18 compared with later initiation has been associated
with the use of other substances (sedatives, opioids, and hallucinogens).6 Also, frequency of use
before age 17 shows a dose-response relationship with other substance use.7

 A recent longitudinal study of youth substance use trends in the United States from 1976 to
2016 found that cannabis is replacing alcohol and tobacco as the first substance used, but did
not analyse subsequent drug use.8 However, adolescents that attempted cigarette smoking
remained at an increased risk of subsequent cannabis use.8

 Research in Vancouver, Canada examined the association between cannabis use and initiation of
injection drug use among 481 street-involved youth involved in a prospective cohort study. In a
model adjusted for other individual characteristics and drug use patterns, the authors found
that daily cannabis use was protective against injection initiation.9

Confounders
 Some studies have described the role of confounding factors that may contribute to the
relationship between cannabis use and other substance use. Examples include peer influence
and co-morbidities such as mental health.1,5

How can we understand the relationship with other

substance use?
 While it is evident that cannabis use may be associated with other substance use, experts
believe that several relationships are involved among social, genetic and environmental factors,
which makes understanding the gateway hypothesis complex.9 These may include adverse
childhood experiences or social influences among those who use substances.

Q&A: Is cannabis a “gateway drug”? 2

  For example, early life experiences can shape the brain’s reward and motivation system, such as
parental neglect or experiencing violence (e.g., bullying), leading to an increased risk of
substance use.10 Additionally, factors that support resilience may reduce substance use.10,11

 Overall, it is unclear whether cannabis use, including frequency or early initiation, causally leads
to the use of other substances. While cannabis use may precede other substance use, the
relationship likely involves multiple other factors, including social conditions.

Which organizations have information available on the

gateway issue?
 Canadian Centre on Substance Use and Addiction: The effects of cannabis use during
adolescence

 National Institute on Drug Abuse: Is marijuana a gateway drug?

Q&A: Is cannabis a “gateway drug”? 3

References
1. Lynskey MT, Agrawal A. Denise Kandel's classic work on the gateway sequence of drug acquisition.
Addiction. 2018;113(10):1927-32.

2. Miller ML, Hurd YL. Testing the Gateway Hypothesis. Neuropsychopharmacology. 2017;42(5):985-6.

3. George T, Vaccarino F. The effects of cannabis use during adolescence. Ottawa, ON: Canadian Centre
on Subtance Abuse; 2015. Available from: www.ccsa.ca/Resource%20Library/CCSA-Effects-of-Cannabis-
Use-during-Adolescence-Report-2015-en.pdf

4. Fergusson DM, Horwood LJ. Does cannabis use encourage other forms of illicit drug use? Addiction.
2000;95(4):505-20.

5. Secades-Villa R, Garcia-Rodriguez O, Jin CJ, Wang S, Blanco C. Probability and predictors of the
cannabis gateway effect: a national study. Int J Drug Policy. 2015;26(2):135-42.

6. Grant JD, Lynskey MT, Scherrer JF, Agrawal A, Heath AC, Bucholz KK. A cotwin-control analysis of drug
use and abuse/dependence risk associated with early-onset cannabis use. Addict Behav. 2010;35(1):35-41.

7. Silins E, Horwood LJ, Patton GC, Fergusson DM, Olsson CA, Hutchinson DM, et al. Young adult
sequelae of adolescent cannabis use: an integrative analysis. Lancet Psychiatry. 2014;1(4):286-93.

8. Keyes KM, Rutherford C, Miech R. Historical trends in the grade of onset and sequence of cigarette,
alcohol, and marijuana use among adolescents from 1976–2016: implications for “gateway” patterns in
adolescence. Drug Alcohol Depend. 2018;194:51-8.

9. Reddon H, DeBeck K, Socia ME, Dong H, Wood E, Montaner J, et al. Cannabis use is associated with
lower rates of initiation of injection drug use among street‐involved youth: a longitudinal analysis. Drug
and Alcohol Review. 2018;37(3):421-28.

10. Resilience: why do some of us bounce back from adversity better than others? [Internet]. Calgary,
AB: Alberta Family Wellness Initiative; 2018; cited 2018 Dec 5]. Available from:
www.albertafamilywellness.org/what-we-know/resilience-scale

11. Sigfúsdóttir ID, Thorlindsson T, Kristjánsson AL, Roe KM, Allegrante JP. Substance use prevention for
adolescents: the Icelandic model. Health Promot Int. 2009;24(1):16-25.

Q&A: Is cannabis a “gateway drug”? 4

Authors
Pamela Leece, Public Health Physician, Health Promotion Chronic Disease and Injury Prevention, PHO

Nimitha Paul, Practicum Student, Health Promotion Chronic Disease and Injury Prevention, PHO

Reviewers
Robert Gabrys, Research and Policy Analyst, Canadian Centre for Substance Abuse

Tamar Meyer, Supervisor, Centre for Addiction and Mental Health

Brent Moloughney, Medical Director, Health Promotion Chronic Disease and Injury Prevention, PHO

Greg Penney, Director of Programs, Canadian Public Health Association

Sheena Taha, Knowledge Broker, Canadian Centre for Substance Abuse

Citation
Ontario Agency for Health Protection and Promotion (Public Health Ontario), Leece P, Paul N. Q & A: Is
cannabis a “gateway drug”? Toronto, ON: Queens’s Printer for Ontario; 2019.

©Queen’s Printer for Ontario, 2019

Disclaimer
This document was developed by Public Health Ontario (PHO). PHO provides scientific and technical
advice to Ontario’s government, public health organizations and health care providers. PHO’s work is
guided by the current best available evidence at the time of publication.

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For Further Information

For more information on cannabis contact Health Promotion, Chronic Disease and Injury Prevention at:
hpcdip@oahpp.ca

Q&A: Is cannabis a “gateway drug”? 5

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