The fast growing movement towards cannabis legalization in the U.S. has generated increased interest in the overlap of cannabis use with other substances, and its potential impact on public health. This fact sheet offers a brief overview of the co-use of cannabis and tobacco. It includes prevalence data from the U.S. National Survey of Drug Use and Health (NSDUH)*, patterns of cannabis and tobacco co-administration, possible risks, and current research gaps.
Prevalence, characteristics, and trends of cannabis and tobacco use
The National Survey on Drug Use and Health (NSDUH) is a nationally representative annual survey and is the primary source of data on the prevalence, patterns, and consequences of alcohol, tobacco, and illegal drug use and abuse and mental disorders in the U.S. civilian, non-institutionalized population, age 12 and older.
According to the 2011-2012 NSDUH, 5.2% of adults 18 and over report using tobacco and cannabis in the last thirty days (Schauer et al, 2015). For comparison, 2.3% reported cannabis use but no tobacco use during the same time period, indicating that the overlap of cannabis and tobacco use is more common than the use of cannabis alone. Another way to look at this same information is to focus only on cannabis users: 78.3 % of last-30-days adult cannabis users report using tobacco during the same period of time (Schauer et al, 2015).
Co-users of cannabis and tobacco differ from cannabis-only users in a number of ways: they are more likely to report heavy drinking (5 or more days of having five or more drinks in the past month) and use of other substances, being male, black, and younger in age (Schauer et al, 2016).
NSDUH trend analysis reveals a significant increase in the co-use of cannabis and tobacco, rising from 4.4% to 5.2% between 2003 to 2012. Notably, this increase was due to an uptake of cannabis by tobacco users rather than the other way around; in fact, the use of tobacco among cannabis users has decreased over that period of time (Schauer et al, 2016).
Co-use patterns: Sequential, substitution, and co-administration
While the prevalence of tobacco and cannabis co-use is known in the U.S., there is scarce research on the actual consumption patterns of this dual use (Schauer et al, 2017). In one qualitative study among Seattle-area adults aged 18-34 years, three modes of marijuana and tobacco co-use were identified, with distinct reasons associated with them (Schauer et al, 2016b).
- Sequential use: More commonly reported by heavy consumers of tobacco, sequential use means using cannabis and tobacco within a short succession. It is described as a way to enhance a cannabis high, to deal with cravings due to addiction to the two substances, or to counteract the effects of each substance (e.g. use of nicotine to counteract the THC high).
- Substitution: Some co-users report liking the act of smoking, regardless of product. They tend to resort to tobacco in occasions where cannabis use is not allowed or appropriate (i.e., during work hours). Others report using one substance (typically cannabis) as a way to cut down or quit the other (typically tobacco).
- Co-administration: Participants reported co-administration of cannabis and tobacco in blunts (cannabis rolled out with tobacco paper, found in cigars), spliffs (rolled tobacco and cannabis), and sometimes using water pipes or bongs. Co-administration seems more common in high-frequency tobacco users. Reported reasons for co-administration include modulating the flavor and effects of these substances or as a way to adjust the dose of either tobacco or cannabis .
What are the potential risks of tobacco and cannabis co-use?
This is an understudied topic. The relatively few studies available vary considerably in quality and methods of inquiry (National Academy of Sciences, 2017, Chapter 14). There is some evidence that:
- Cannabis users who also use tobacco have poorer cannabis cessation outcomes, when compared to cannabis users alone [Meier & Hatsukami, 2016; Haney et al, 2013; Peters et al, 2012, 2014).
- Co-users experience greater respiratory symptoms when compared with exclusive tobacco smokers (Ramo et al, 2012).
- Co-use may pose additive risk for toxicant exposure. Blunt users tend to have higher carbon monoxide exposure levels than tobacco-only users (Meier & Hatsukami, 2016).
- Co-use has a differential effect on learning and memory when compared with cannabis use alone (Subramaniam et al, 2016; Hindocha et al, 2017).
- Co-use during pregnancy appears to increase risk of adverse perinatal outcomes more than use of either substance alone. (Chabarria et al, 2016).
Further research needed
Legalization of cannabis in many U.S. states is changing the substance use landscape rapidly. Knowledge produced before legalization may not apply in states where cannabis is available in retail stores for any adult 21 and over and where cannabis stores are advertised in billboards, as is the case in Washington. Longitudinal population surveys and comparative studies of cannabis policies are needed as they will continuously bring new discoveries in future years. It is important to keep in mind, however, that cannabis legalization for non-medical purposes is still too recent to indicate the net result of legal cannabis on co-use and/or tobacco use rates (Pacula & Sevigny, 2014).
Some of the most pressing areas in need of further research are:
More NSDUH analysis using 2013 or more recent data and making state comparisons is needed to monitor changes in prevalence and patterns of cannabis and tobacco co-use. New devices have the potential to change behaviors, e.g. portable vaporizers with temperature control and tanks that allow tobacco or cannabis consumption using only one device, which increases the likelihood of co-use (McDonald et al, 2016). On the other hand, the legalization of cannabis may decrease the need of substituting cannabis for tobacco in certain circumstances, thereby decreasing co-use.
Health consequences of co-use
The research in this area is incipient and somewhat inconclusive (National Academy of Sciences, 2017; Subramaniam et al, 2016). It is possible that the health consequences vary by co-use pattern. Co-administration may differ from sequential use in terms of nicotine exposure and absorption, or in terms of THC-related impairment.
Effects of cannabis policy on tobacco use
Tobacco use kills almost a half million Americans each year. Enthusiasts of lifting cannabis prohibition have long advocated that more accessibility to cannabis could encourage substitution of tobacco by cannabis, a less-harmful product not associated with high mortality (Hindocha et al, 2016). Those less favorable towards cannabis legalization argue that any increase in use of a specific substance may result in increased use of other substances as well, including tobacco. More research is needed to explore these hypotheses, with a focus on vulnerable populations such as pregnant women, those with low income, and racial and ethnic minorities.
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- National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press, 2017. doi: 10.17226/24625.
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Citation: Carlini BH. Cannabis and Tobacco Use. Addictions, Drug & Alcohol Institute (ADAI), University of Washington, August 2017.
This report was produced with support from the Washington State Dedicated Marijuana Fund for research at the University of Washington.