Adolescent Marijuana Use and Co-Occurrence with Tobacco Use: Implications for Tobacco Regulation

Background: Marijuana use among high school youth has been declining over the past two decades. However, there has been a notable shift in the national landscape with regards to social norms and marijuana legalization that could allow marijuana to become more available and may compete against prevention efforts among youth. Further, youth continue to utilize innovative ways to consume marijuana. There is a documented relationship between marijuana and tobacco use, particularly with the use of blunts. Despite the documented relationship between tobacco and marijuana use, little is known about the modes of marijuana use in relation to different tobacco products. With the recent FDA changes bringing cigars under the purview of the FDA Center for Tobacco Products (CTP), there may be an opportunity for CTP regulations of cigar products to impact youth use of both marijuana and tobacco. Methods: This study used data from the 2015 Cleveland Youth Risk Behavior Survey (n=6197) conducted as a census administration in 26 high schools; overall response rate was 66.5%. Youth were asked “During the past 30 days, how did you usually use marijuana?”. Responses were coded as a blunt; in a joint, bong, or pipe (JBP); or some other way. The standard CDC response categories for this item were altered to allow us to specifically examine blunt use. Analyses were restricted to those who smoked marijuana in the past 30 days and were conducted using SPSSv24. Demographic and tobacco use characteristics were examined for each mode of marijuana use. Result: Overall, 74.6% of past 30-day marijuana users reported usually smoking marijuana as a blunt, 15.1% smoked as a JBP, and 10.4% reported using in some other way. Females were more likely to smoke a blunt (79.5% v 71.1%) and less likely to use some other way (6.7% v 13.1%). Blacks were more likely to smoke a blunt compared to Whites and Hispanics (80.8% v 62.3% and 67.0% respectively); Whites were more likely to smoke a JBP compared to Black and Hispanics (33.8% v. 8.9% and 20.1% respectively). Past 30-day cigarette smokers were more likely to have smoked a JBP and less likely to have smoked a blunt compared to non-cigarette smokers. Conversely, past 30-day cigar smokers were more likely to have smoked a blunt and less likely to have smoked a JBP than non-cigar smokers. Youth who vaped in the past 30-days were more likely to use a JBP and use marijuana in some other way compared to youth who had not vaped. In a multivariable logistic regression predicting blunt use or JBP use, cigar product use increased odds of blunting (OR: 1.98) while hookah use was associated with increased odds of JBP. Conclusion: Cigar products are an easily accessible vehicle for smoking marijuana. Federal regulations to restrict youth access to cigar products could have significant impact on adolescent marijuana use, particularly among females and Black youth