The relevance of age at first alcohol and nicotine use for initiation of cannabis use and progression to cannabis use disorders

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Abstract

Background

A younger age at onset of use of a specific substance is a well-documented risk-factor for a substance use disorder (SUD) related to that specific substance. However, the cross-substance relationship between a younger age at onset of alcohol use (AU) and nicotine use (NU) and the risk of cannabis use disorders (CUD) in adolescence and early adulthood remains unclear.

Aims

To identify the sequence of and latency between initial AU/NU and initial cannabis use (CU). To investigate whether younger age at AU- and NU-onset is associated with any and earlier CU-onset and a higher risk of transition from first CU to CUD, taking into account externalizing disorders (ED) and parental substance use disorders as putative influential factors.

Methods

Prospective-longitudinal community study with N = 3021 subjects (baseline age 14–24) and up to four assessment waves over up to ten years with additional direct parental and family history information. Substance use and CUD were assessed with the DSM-IV/M-CIDI.

Results

Most subjects with CU reported AU (99%) and NU (94%). Among users of both substances, 93% reported AU prior to CU (87% for NU). After adjustment for ED and parental substance use disorders younger age at AU-onset was associated with any CU. Younger age at NU-onset was associated with earlier CU initiation. Younger age at AU- and NU-onset was not associated with a higher risk of CUD.

Conclusions

The cross-substance relevance of younger age at first AU and NU for the risk of CUD is limited to early CU involvement.

Introduction

A younger age at onset of use of a specific substance is a well-documented risk factor for substance use disorders (SUD, DSM-IV-substance abuse or dependence) related to this specific substance (Behrendt et al., 2009, Breslau et al., 1993, Buchmann et al., 2009, Chen et al., 2005, Dawson et al., 2008, DeWit et al., 2000). Nevertheless, there are still restrictions to the understanding of the role of younger age at onset of substance use (SU) in substance use disorder development. It remains unclear whether younger age at substance use onset is a substance-specific risk-factor or a risk factor for substance use disorders across substance classes. It is also unclear whether a cross-substance association between a younger age at substance use onset and substance use disorders is independent of important influential factors that may constitute a general underlying vulnerability for early substance use and SUD. Therefore, we investigate the cross-substance relationship between younger age at onset of use of one substance for the risk of substance use disorders related to another substance. Here, we focus on the role of younger age at onset of alcohol use (AU) and nicotine use (NU) for the risk of cannabis use disorders (CUD). This is due to several reasons: at least experimental AU and NU are almost normative experiences in adolescence in western societies and most likely the first substance use experiences (Poelen et al., 2005, Wittchen et al., 2008, Young et al., 2002). Epidemiological evidence indicates that adolescents are unusually naïve to AU and NU at first cannabis use (CU) (Bonomo et al., 2004, Everett et al., 1999, Hayatbakhsh et al., 2007, Kandel and Yamaguchi, 1993, Monshouwer et al., 2005, Palmer et al., 2009, Patton et al., 2002, Poelen et al., 2005, Wagner and Anthony, 2002a, Wittchen et al., 2008, Young et al., 2002). Cannabis is the most widely used illegal substance in western societies (European Monitoring Centre for Drugs and Drug Addiction, 2010, United Nations Office on Drugs and Crime, 2010). For a proportion of users CU leads to CUD, considerable psychosocial sequelae and treatment need (Coffey et al., 2002, European Monitoring Centre for Drugs and Drug Addiction, 2010, Georgiades and Boyle, 2007, Hayatbakhsh et al., 2007, Patton et al., 2002). Investigating the relationship between younger age at onset of AU and NU and the risk of CUD is important for early identification of youth at risk of CUD and for the planning of timely preventive efforts. For this matter, it is also important to investigate the latency between first AU/NU and first CU-involvement.

To date, the specific relationship between a younger age at first AU and NU and CUD risk remains unclear, despite well-documented general cross-substance associations for any substance use and substance use disorders (Grucza and Bierut, 2006, Lynskey et al., 2003, Palmer et al., 2009). Such relationships may exist because any AU and NU as well as younger age at AU- and NU-onset are associated with the risk of at least experimental CU and younger age at CU-onset (Caris et al., 2009, Kokkevi et al., 2006, Sartor et al., 2009, von Sydow et al., 2002, Wagner and Anthony, 2002b), the latter of which predicts CUD (Chen et al., 2005).

It also remains unclear whether primacy of AU or NU (i.e., which of the two substances was tried first) which may indicate a deviant substance use initiation pattern and thus CUD risk and prevention need, plays a role in this regard (Degenhardt et al., 2009). Importantly, other factors may also play a role in the relationship between younger age at first AU and NU and the risk of CUD. It has been proposed that early use of different substances and different substance use disorders share underlying influential factors (Morral et al., 2002, Palmer et al., 2009, Sartor et al., 2009), most importantly externalizing disorders, genetic factors, and familial SUD. Externalizing disorders and parental substance use disorders are related to offspring substance use disorders and younger age at substance use onset (Elkins et al., 2007, King et al., 2004, Lieb et al., 2001, Lieb et al., 2002, McGue and Iacono, 2008, Obot et al., 2001). However, younger age at first AU is a risk factor for alcohol use disorders independent of these factors (Dawson et al., 2008), underlining the possible specific importance of younger age at substance use onset (Agrawal et al., 2009). As shown for alcohol, neurodegenerative effects of early substance use may lead to reduced behavioral control (Nixon and McClain, 2010), a factor relevant for all kinds of substance use disorders including CUD (Elkins et al., 2007, Hayatbakhsh et al., 2008). Therefore, we hypothesize to find a cross-substance relationship between younger age at AU- and NU-onset and an elevated CUD risk independent of younger age at CU-onset, externalizing disorders and parental SUD. Considering these factors can help understanding the role of early AU/NU in CUD etiology and identifying the most important indicators of CUD risk.

We investigate in a community sample of adolescents and young adults

  • (1)

    the sequence of and latency between AU/NU and CU initiation,

  • (2)

    whether a younger age at AU-onset and younger age at NU-onset are associated with a higher risk of any CU, younger age at first CU, and CUD,

  • (3)

    whether the association between a younger age at AU-onset and younger age at NU-onset and the risk of any CU and younger age at first CU is independent of externalizing disorders, parental alcohol dependence and parental illegal substance dependence; whether the association between a younger age at AU-onset and younger age at NU-onset and the risk of CUD is independent of externalizing disorders, parental alcohol and illegal substance dependence and younger age at CU-onset,

  • (4)

    whether results for (2) and (3) differ by primacy of AU or NU.

Section snippets

Study sample and design

The prospective-longitudinal EDSP (Early Developmental Stages of Psychopathology) study investigates vulnerabilities and risk-factors of substance use and disorders in a community sample of 3021 adolescents and young adults aged 14–24 at study baseline (T0). The study includes three follow-up assessments (T1, T2, T3). Detailed information on the study has been provided (Beesdo et al., 2007, Lieb et al., 2000, Wittchen et al., 1998b). The baseline sample was randomly drawn from government

Sequence of and latency between AU/NU and CU initiation

As reported previously (Wittchen et al., 2008), the cumulative incidence rate up to T3 was 97.7% for AU, 79.2% for NU and 50.7% for CU. The main incidence periods (i.e., the steepest increase in the Kaplan–Meier estimates for cumulative lifetime incidence) were ages 10–16 (AU), 11–17 (NU) and 14–19 (CU).

Almost all subjects with lifetime CU reported lifetime AU (99.6%) and NU (94.7%).

Most (93.0%) users of alcohol and cannabis reported first AU as prior to CU. 4.4% reported AU and CU initiation

Discussion

We investigated the cross-substance relationship between, respectively a younger age at onset of alcohol use and a younger age at onset of nicotine use and the risk of cannabis use disorders, taking into account age of cannabis use onset, externalizing disorders, and parental substance use disorders as important influential factors for the risk of cannabis use and disorders. The main findings are: (1) Almost all cannabis users had prior experience with alcohol (99.6%) and nicotine (94.7%) use.

Role of funding source

This paper was prepared in the context of the project ‘Community-based need evaluation II and allocation and transfer’ (primary investigator: H.-U. Wittchen) of the German Addiction Research Network ASAT (Allocating Substance Abuse Treatments to Patient Heterogeneity). This work is a further part of the Early Developmental Stages of Psychopathology (EDSP) Study and is funded by the German Federal Ministry of Education and Research (BMBF) project nos. 01EB9405/6, 01EB9901/6, EB01016200, 01EB0140

Contributors

Dr. Silke Behrendt planned the analysis and wrote the manuscript.

Dr. Buehringer, Dr. Beesdo-Baum, Dr. Perkonigg, Dr. Wittchen, Dr. Lieb and Dr. Höfler provided supervision of and substantial contribution to the writing of the manuscript.

Dr. Höfler also provided supervision and substantial contribution to the planning and conduction of the statistical analysis. All authors contributed to and have approved of the final version of the manuscript.

Conflict of interest

Gerhard Bühringer: Alcohol, pharmaceutical and tobacco industry: none. Gaming industry: research has been funded by the Bavarian State Ministry of the Environment and Public Health (State gambling monopoly) and organisations of the gaming industry (private gambling).

Dr. Hans-Ulrich Wittchen has no connection with the alcohol and tobacco industry. Dr. Wittchen is and has been a member of advisory boards of several pharmaceutical companies. He has received travel reimbursements and research grant

Acknowledgements

The principal investigators of the EDSP study are Dr. Hans-Ulrich Wittchen and Dr. Roselind Lieb. Core staff members of the EDSP group are: Dr. Kirsten von Sydow, Dr. Gabriele Lachner, Dr. Axel Perkonigg, Dr. Peter Schuster, Dr. Michael Höfler, Dipl.-Psych. Holger Sonntag, Dr. Tanja Brückl, Dipl.-Psych. Elzbieta Garczynski, Dr. Barbara Isensee, Dr. Agnes Nocon, Dr. Chris Nelson, Dipl.-Inf. Hildegard Pfister, Dr. Victoria Reed, Dipl.-Soz. Barbara Spiegel, Dr. Andrea Schreier, Dr. Ursula

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