The focal point of this paper is the transition from drug use to drug dependence. We present new evidence on risk for starting to use marijuana, cocaine, and alcohol, as well as risks for progression from first drug use to the onset of drug dependence, separately for each of these drugs. Data from the National Comorbidity Survey (NCS) were analyzed. The NCS had a representative sample of the United States population ages 15-54 years (n ϭ 8,098In an earlier report of evidence from the National Comorbidity Survey, our research group described some interesting features about the comparative epidemiology of drug dependence. For example, as a summary population average value for the estimated millions of Americans age 15-54 years who had tried cocaine at least one time by the early 1990s, about one in six had become dependent upon cocaine (about 16-17% NO . 4 marijuana at least one time, about one in 11 had become dependent upon it (about 9%). By comparison, among persons who had tried alcoholic beverages at least once, about one in 6 or 7, or 15%, had become alcohol dependent (Anthony et al. 1994). In the present study, we extend this look at the comparative epidemiology of drug dependence, but here our focus is upon estimation of the age-specific and time-specific risks of progression from first drug use to dependence, separately for marijuana, cocaine, and (for comparison) alcoholic beverages (hereinafter, 'alcohol').Prior studies have conveyed estimates of age-specific risk for first alcohol use and alcohol dependence, as well as risk estimates for initiation of illicit use and dependence on controlled drugs in general (e.g., Kandel and Logan 1984;Eaton et al. 1989;Warner et al. 1995;Chen and Kandel 1995;Johnson and Gerstein 1998;Perkonigg et al. 1999;DeWit et al. 2000). The role of early onset of drug use and progression to initial and problematic use of other drugs also has been studied in some detail (e.g., Kandel 1985;Anthony and Petronis 1995;Grant 1998;Grant and Dawson 1998). However, what is especially novel about the present study is its new look at both the cumulative and instantaneous risk of drug dependence in relation to time elapsed since first use of marijuana and cocaine, with alcohol for comparison.Whereas epidemiological studies of this type generally are regarded as valid sources of evidence, it is possible that some critics might call into question the validity or reliability of drug dependence assessments obtained in large-sample survey research as compared with what can be obtained via intensive clinical study of smaller samples (e.g., see Anthony et al. 1985;Brugha et al. 1999). Nonetheless, at least with respect to the drug dependence syndromes, recent empirical research provides evidence that epidemiologic studies can and do provide generally valid and reliable estimates of the occurrence of these conditions, as well as their corresponding ages of onset (e.g., see Prusoff et al. 1988;Langenbucher et al. 1994;Shillington et al. 1995;Wittchen et al. 1989Wittchen et al. , 1998Wittchen et ...
Drawing upon an "exposure opportunity" concept described by Wade Hampton Frost, the authors studied two mechanisms to help account for prior observations about the "stepping-stone" or "gateway" sequences that link the use of alcohol, tobacco, marijuana, and cocaine. Data were obtained from four nationally representative and independent cross-sectional samples of US household residents (n = 44,624 persons aged 12-25 years). Data were gathered using standardized self-report methods and were analyzed via survival methods. Results indicated that users of tobacco and alcohol were more likely than nonusers to have an opportunity to try marijuana and were more likely to actually use marijuana once a marijuana opportunity had occurred. Opportunity to use cocaine was associated with prior marijuana smoking. Among young people with a cocaine opportunity, those who had used marijuana were more likely to use cocaine than were those with no history of marijuana use. The observed associations did not seem to arise solely as a result of young drug users' seeking out opportunities to use drugs. Applying Frost's epidemiologic concept of exposure opportunity, the authors offer new epidemiologic evidence on the sequences that link earlier use of alcohol and tobacco to later illegal drug involvement.
Using a modified social ecological model, we conducted a review of the literature and nationwide statistics on African American health. We discuss the main social determinants of health and main health disparities, risk factors, the leading causes of morbidity and mortality, and access to health services for blacks in the USA. The mechanisms through which social determinants, including racism, exert their deleterious effects on black health are discussed at the macro and individual levels. Incarceration and mental health care issues are highlighted as priorities to be addressed. African Americans remain the least healthy ethnic group in the USA, a somber legacy of years of racial and social injustice and a formidable challenge to equitable health care for all. Systemic causes of suboptimal black health require equally systemic solutions; positive trends in black health indicators seem to be driven by social development programs, economic investment in education, participation of African Americans in policy, and decision-making and expansion of access to health care.
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