Products Involved in Tobacco and Cannabis Co-Use Among US Adults & Youth, 2022–2023

Introduction

Concurrent use (co-use) of tobacco and cannabis is common among both adults and youth¹. Co-use is linked to greater dependence and difficulty quitting both substances², and increased toxicant exposure³. Overwhelmingly, co-use research has not established the most prevalent tobacco and cannabis product combinations involved. Improving understanding of this issue is important to guide emerging research involving smoking and vaping, since both substances are often consumed through these modalities. We examined prevalence of tobacco-cannabis co-use and the most common product combinations among US adults and youth.

Methods

Cross-sectional data were from Wave 7 (2022–2023) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study, conducted among US non-institutionalized civilians. Weighted response rates for adults and youth, respectively, were 52.4–66.9% and 54.3–64.0%, depending on recruitment wave. The current analytic sample included older adults (26+, n=18,136), young adults (18–25, n=11,335), and youth (12–17, n=10,065) with complete data on tobacco and cannabis product use. The study was approved by the Institutional Review Board at Westat (Rockville, MD; Registration #0000695; Federal Wide Assurance #FWA00005551); methods are detailed elsewhere⁴.

Population prevalence estimates with 95% confidence intervals (CIs) were calculated for past 30-day co-use of any tobacco and cannabis product. Among co-users (older adults n=2,575; young adults n=1,710; youth n=230), we determined prevalence of mutually exclusive product combinations (Table S1). Tobacco products included: cigarettes, e-cigarettes, cigars (traditional, filtered, cigarillos), pipes, hookah, snus, smokeless tobacco, heated tobacco (e.g. IQOS), nicotine pouches, other oral tobacco (e.g. lozenges), and bidis (youth only). Cannabis products included: smoked cannabis only (e.g. joint, bong), blunts (cannabis smoked with tobacco in a cigar, cigarillo, or filtered cigar), vaped oils/distillates, vaped herb, edibles, topicals/tinctures, dabs (vaporized concentrates), cannabidiol (CBD) only, and other forms. Weighted analyses were conducted using Stata v18 (Table S1).

Results

Tobacco-cannabis co-use prevalence was highest among young adults (15.6%, 95%CI: 14.8–16.4%), followed by older adults (7.8%, 95%CI: 7.3–8.2%), and youth (2.0%, 95%CI: 1.7–2.3%). The most prevalent product combinations (Figure 1,Table S1) included cigarettes and smoked cannabis only (21.8%, 95%CI: 19.9–23.8%) among older adults (Figure 1A), e-cigarettes and smoked cannabis only (10.4%, 95%CI: 8.8–12.2%) among young adults (Figure 1B), and e-cigarettes and vaped cannabis oils/distillates (17.2%, 95%CI: 12.5–23.2%) among youth (Figure 1C). Examining only combinations of inhaled products (cigarettes, e-cigarettes, smoked cannabis [alone and blunts], vaped cannabis oils/distillates), the most prevalent combinations included cigarettes and smoked cannabis among older adults (40.1%, 95%CI: 37.8–42.4%), e-cigarettes and smoked cannabis among young adults (24.3%, 95%CI: 22.2–26.5%), and e-cigarettes, smoked cannabis, and vaped cannabis oils/distillates among youth (34.0%, 95%CI: 27.6–40.9%).

Discussion

Tobacco-cannabis co-use was more prevalent among adults than youth. Findings may be limited by the data’s self-report nature, and lack of biochemically verified product use. While older cohorts prefer smoked tobacco and cannabis, younger adults and youth show a transition in preference to vaped forms⁵. As product markets and consumer behaviors evolve, it is increasingly important for nicotine and tobacco researchers to evaluate the specific products involved in co-use to help improve research precision and identify key populations for harm reduction interventions.