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. Author manuscript; available in PMC: 2024 May 1.
Published in final edited form as: Drug Alcohol Depend. 2023 Mar 12;246:109837. doi: 10.1016/j.drugalcdep.2023.109837

Blunt and Non-Blunt Cannabis Use Associated with Cigarette, E-Cigarette, and Cigar Initiation: Findings from the Population Assessment of Tobacco and Health (PATH) Study

Brian J Fairman 1, Heather L Kimmel 2, Carlos Blanco 2, Wilson M Compton 3
PMCID: PMC10161973  NIHMSID: NIHMS1884046  PMID: 36931132

Abstract

Background:

Smoking cannabis using a tobacco-derived cigar shell or wrap, called blunt smoking, exposes individuals to non-trivial amounts of nicotine. The extent smoking blunts impact the risk of initiating other tobacco products is not well understood. We investigated if past-year blunt smoking is related to the risk of initiating cigarettes, e-cigarettes, and cigars.

Methods:

We obtained data on a nationally representative, non-institutionalized, civilian cohort of US residents aged 12 years and older who had never used cigarettes, e-cigarettes, or any cigar at baseline and surveyed annually for three years from the Population Assessment of Tobacco and Health Study. We estimated the proportional hazard (odds) of initiating these tobacco products associated with past-year blunt smoking, non-blunt cannabis use, or neither using discrete-time survival analyses.

Results:

Smoking blunts increased the risk of starting cigarettes (OR = 4.5), e-cigarettes (OR = 3.7), and cigars (OR = 6.7) compared to using neither blunts nor cannabis. Non-blunt cannabis use also increased the risk of starting cigarettes (OR = 4.0) but moderately for e-cigarettes (OR = 2.8) and any cigar (OR = 2.2). Blunt use was strongly related to starting combustible tobacco (cigarettes or cigars; OR = 9.0) and any three tobacco products (OR = 10.9). Exploratory findings showed that cigarillos drove cigar results and effect modification by age, race/ethnicity, and sex.

Conclusions:

People who smoke blunts risk starting cigarettes, e-cigarettes, and cigars more than those who abstain from cannabis. Blunts may contribute to tobacco initiation above cannabis alone.

Keywords: Blunts, cannabis, cigarette, e-cigarette, cigar, cigarillo

Introduction

Blunt smoking involves removing some or all loose tobacco from a cigar and replacing it with cannabis. Blunt smoking originated in and has been the most studied in the United States (US), where 12% of young adults and 4% of youth smoked blunts in the past month as of 2014 (Montgomery & Mantey, 2017a, 2017b). Among people using cannabis in the past year surveyed in 2009–2012, 40% smoked a blunt in the past month, and 8% smoked blunts daily or near-daily (Fairman, 2015). People who smoke blunts are disproportionately young adults, male, and Black (Corey et al., 2018; Montgomery & Mantey, 2017b). Outside the US, national prevalence estimates of blunt smoking are lacking. Nonetheless, one study found that around 35% of Ontario, Canada youth who used cannabis in the past 12 months smoked blunts (Kolar et al., 2020). In another study, 6.1% of adults who used cannabis in the past year in Mexico smoked blunts, 2.8% in Brazil, and 2.0% in France compared to 3.4% in the US (Hindocha et al., 2016). These findings suggest blunt smoking is not strictly a US phenomenon.

Cannabis use poses health risks, but a significant concern is whether blunt smoking contributes to tobacco-related harms (U.S. Department of Health and Human Services, 2012; Volkow et al., 2014) for youth and young adults. Although cigarette initiation has declined among youth, it has increased among young adults (Cantrell et al., 2018). Studies also suggest little change in cigar use trends among youth and young adults and increased use in specific populations, like Black women (East et al., 2021; Weinberger et al., 2019). Blunts are a concern for further tobacco use because they contain non-trivial amounts of nicotine (1.2 to 6.0 mg), exposing individuals who smoke them to significant levels, but are perceived as less harmful than cigarettes or cigars (Nardone et al., 2019; Peters et al., 2016; Sterling et al., 2016). Since cannabis use alone increases tobacco use (Cornacchione Ross et al., 2020; Patton et al., 2005; Weinberger et al., 2021), it is unclear whether blunt smoking might contribute further to this risk.

Significant gaps remain in our understanding of whether blunt smoking contributes to the risk of using other tobacco products. For example, Hu and colleagues (2008) observed that youth who initiated smoking blunts before cigarette use increased their likelihood of early and sustained nicotine dependence. Audrain-McGovern and others (2019) found that youth who had ever smoked blunts were likelier to progress to current cigar use. Unfortunately, neither of these studies assessed the risk of initiating cigarettes or cigars. More recently, Mayer and colleagues (2019) reported that Connecticut and California youth who smoked blunts were twice as likely to initiate combustible tobacco (cigarettes or cigars) compared to youth who never used cannabis but not compared to non-blunt cannabis use.

We sought to build upon this prior literature by investigating whether past-year blunt smoking is associated with initiating different tobacco products in a cohort of youth and adults followed prospectively over three years. We examined the independent risk of initiating cigarettes and cigars but also explored the initiation of either combustible product, as in Mayer et al. (2019). Further, given the epidemic of nicotine vaping among youth and the links between cannabis and e-cigarette use, we additionally examined e-cigarette initiation (Chen et al., 2018; Seo et al., 2020). We hypothesized that people who smoked blunts in the past year would be at an increased risk of starting to use cigarettes, e-cigarettes, and cigars for the first time. The increased risk would be relative to those who used cannabis but not blunts (non-blunt cannabis) and those who used neither. We further expected that the risk would be greater for cigar initiation, given their use in blunt construction, followed by cigarettes and e-cigarettes. Lastly, we explored initiation by cigar type (traditional, cigarillo, and filtered cigars), any of the three tobacco products studied (cigarettes, e-cigarettes, or cigars), and interactions with age, race, and sex.

Methods

Study Design

The National Institutes of Health (NIH), through the National Institute on Drug Abuse (NIDA), has partnered with the Food and Drug Administration’s (FDA) Center for Tobacco Products (CTP) to conduct the Population Assessment of Tobacco and Health (PATH) Study. The PATH Study is an ongoing, nationally representative, longitudinal cohort study of non-institutionalized adults and youth in the US. It uses audio computer-assisted self-interviews (ACASI) available in English and Spanish to collect self-reported information on tobacco-use patterns and associated health behaviors. Recruitment for the Wave 1 cohort employed a stratified address-based, area-probability sampling design at Wave 1 that oversampled adults who use tobacco, young adults (18 to 24 years), and Black adults. An in-person screener was used at Wave 1 to randomly select youths and adults from households for participation in the study (Hyland et al., 2017). We excluded youth interviewed for the first time in Waves 2 and 3 because the PATH Study did not ask them about non-blunt cannabis use in the past year.

The PATH Study surveyed a total of 13,651 youth (12–17) and 32,320 adults (18+) at Wave 1 (September 2013-December 2014). Weighted response rates for youth and adults were 78.4% and 74.0%, respectively. Interviewers surveyed participants for Waves 2–4 close to their 1-year anniversary of participation in the previous wave. The unweighted attrition rate among the Wave 1 cohort was 16.4% at Wave 2, 21.8% at Wave 3, and 27.4% at Wave 4. We analyzed the publicly available data from the PATH Study Waves 1–4 Public Use Files (PUF) (United States Department of Health and Human Services et al., 2012). We excluded a small number of participants (n=6) who requested their data removed. Further details regarding the PATH Study design and methodology are published elsewhere (Hyland et al., 2017). Information about interviewing procedures, questionnaires, sampling, weighting, response rates, and data access are described in the PATH Study PUF User Guide found at https://doi.org/10.3886/Series606. Westat administered the PATH Study, and the Westat Institutional Review Board approved the protocols. All adult respondents gave informed consent. Youth respondents gave assent while their parent/legal guardian provided consent.

Measures

Outcomes: Initiation of Cigarettes, E-Cigarettes, and Cigars

We had three primary outcomes: time to the first use of cigarettes, e-cigarettes, and any cigar (traditional, cigarillo, or filtered cigars) among those at risk for those outcomes at baseline (Wave 1). We defined time in terms of years, with each follow-up wave occurring, on average, one year after the last interview. Respondents were at-risk if they had never used the tobacco product at baseline. We coded respondents as missing if they had ever used the tobacco product at baseline since they could not be at risk for initiation in subsequent waves (they would be considered left-censored). Respondents were asked if they had used each tobacco product in the preceding 12 months at each annual follow-up wave. The first wave that participants used the tobacco product defined the time-to-event for those who experienced the event—the last wave of continuous observation defined the time-to-event for those who did not experience the event (censored). Therefore, the first wave that at-risk respondents could initiate tobacco product use would be Wave 2. Our exploratory outcomes included the time to the first use of a specific cigar type (traditional, cigarillo, and filtered), any combustible tobacco (cigarettes or cigars), and any three product types (cigarettes, e-cigarettes, or any cigar).

At Wave 1 (2013–2014), respondents were asked about e-cigarettes and provided examples of popular brands, including NJOY®, Blu®, or Smoke Everywhere®. Respondents were asked more broadly about e-cigarettes and other electronic nicotine devices (ENDS) starting in Wave 2 (2014–2016). Descriptions included e-cigarettes, e-cigars, e-pipes, e-hookahs, personal vaporizers, vape pens, and hookah pens, with brand examples updated to reflect market popularity and new brands (e.g., Juul®).

Exposure of Interest: Past-Year Blunt Use

The PATH Study defined blunts as, “Sometimes people take tobacco out of a cigar, cigarillo or filtered cigar and replace it with marijuana. This is sometimes called a ‘blunt’‖. Respondents reported whether they had smoked blunts in the past 12 months at each wave. Separately, respondents said if they last used “marijuana, hash, THC, grass, pot or weed” in the past 12 months. We defined past-year blunt use as using blunts, cannabis but not blunts (non-blunt cannabis), or neither in the past 12 months.

Covariates

Our conceptual models considered time-invariant and time-varying covariates. Time-invariant covariates included the respondents’ sex, race or ethnicity, and Census region of residence in Wave 1. Time-varying covariates included age, income, other substance use, household tobacco use, and mental health assessed in Waves 1–4. Adults and parents/guardians of youth reported total annual family income. All respondents reported past-month use (yes/no) of cigarettes, e-cigarettes, any cigars, other tobacco products (pipes, hookah, and smokeless), alcohol, and other drug use (Ritalin®, Adderall®, painkillers, sedatives, tranquilizers, cocaine or crack, stimulants like methamphetamine or speed, and any other drugs like heroin, inhalants, solvents, or hallucinogens). Both adults and youth reported their recent mental health and whether they lived with a tobacco user. The PATH Study assessed mental health problems using a modified Global Appraisal of Individual Needs − Short Screener (GAIN-SS) (Dennis et al., 2006). Following Conway et al. (2018), we summed four items for the internalizing problem subscale (range: 0–4) and seven items for the externalizing problem subscale (range: 0–7); scale reliability (Cronbach’s alpha) was 0.82 and 0.72, respectively.

Statistical Analysis

Missing Data and Bias

The PATH Study imputed missing data on sex, race/ethnicity, and age at Waves 1 and 4 using responses from the household screener and statistical imputation; there was no missing data on the Census region. We logically imputed missing values on age for a small number (n=6) of participants using information from other waves. Annual family income had the most missing data, ranging from 6.2% (Wave 4) to 9.8% (Wave 1, adults only). The PATH Study did not assess income for youth via parental report until Wave 2. We imputed missing data on income based on the respondent’s median value of responses across all waves rounded down to the nearest integer. Pairwise correlations between respondents’ median and observed values were high (>0.88). Imputation reduced missing data on income for adults to less than 3.4% and less than 10.7% for youth. Otherwise, we based analyses on complete cases.

Lifetables and Discrete-Time Survival Analysis

We initially examined time to tobacco initiation using a lifetable approach and stratifying by past-year blunt use status. We then conducted a series of discrete-time survival analyses (DTSA) to estimate the hazard of initiating cigarettes, e-cigarettes, and any cigar associated with past-year blunt and non-blunt cannabis use, controlling for time-invariant and time-varying covariates. Standard logistic regression models can estimate the proportional hazards (as odds ratios) after the data are expanded to person-years, such that respondents contribute a row of data for each year observed (Ziegel & Allison, 1997). In addition to providing relative risk measures, we estimated absolute numbers of tobacco initiates in the population by past-year blunt use and non-blunt cannabis use status based on our models. In exploratory analyses, we examined differences in initiation by cigar type (traditional, cigarillo, and filtered cigars), combustible tobacco use (cigarettes or any cigar), and any tobacco use (cigarettes, e-cigarettes, or cigars). Finally, we explored effect modification by age, race/ethnicity, and sex by including model interaction terms, and then estimated the predicted probability of initiating each tobacco product. All of our analyses except the lifetables accounted for the PATH Study’s complex survey design and respondent non-response across waves using balanced repeated replication (BRR) weights (Wave 1 Cohort) with Fay’s adjustment (p = 0.3). We conducted all analyses using Stata version 17 (StataCorp, 2021).

Results

Characteristics of Participants At Risk for Tobacco Initiation at Baseline

Most people at baseline (Wave 1) had never used e-cigarettes (82.9%) or any cigar (62.6%), while a minority had never smoked cigarettes (38.1%; Table 1). Those who had never vaped e-cigarettes used blunts in the past year at higher rates (2.7%) than those who had never smoked any cigar (0.9%) or cigarettes (1.4%). Most at-risk respondents were female, especially those who had never used any cigar (63.3%). People who never smoked cigarettes were younger (51.3% under age 35), while those who had not initiated e-cigarettes or any cigar were older (33.8% and 38.4% under age 35, respectively). Most at-risk respondents were non-Hispanic White, but non-Whites were more likely to report never smoking cigarettes (44.7%) than e-cigarettes (36.0%) or any cigar (38.4%). Most people lived in households earning below the US median in 2014 (approximately $50,000), and a plurality lived in the South. We present distributions for all covariates measured at Wave 1 in Supplemental Table S1.

Table 1.

Characteristics of the PATH Study Wave 1 Cohort Who Never Used Cigarettes, E-Cigarettes, or Any Cigar

Cigarettes E-Cigarettes Any Cigar
Covariates1 n Wgt% n Wgt% n Wgt%
Never Used @ Wave 1
 Total 18,907 38.1% 32,888 82.9% 26,414 62.6%
Past-Year Blunt Use
 Neither 17,705 96.4% 29,007 92.9% 24,334 95.8%
 Non-Blunt Cannabis 607 2.2% 1,890 4.5% 1,330 3.3%
 Blunts 472 1.4% 1,679 2.7% 527 0.9%
Sex
 Male 8,962 42.5% 16,420 47.1% 10,986 36.7%
 Female 9,945 57.5% 16,468 52.9% 15,428 63.3%
Age
 12–14 6,557 11.8% 6,618 5.5% 6,602 7.5%
 15–17 5,235 9.8% 5,538 4.7% 5,671 6.7%
 18–24 3,144 14.4% 5,209 9.6% 3,902 10.6%
 25–34 1,168 15.3% 3,503 13.9% 2,277 13.6%
 35 or older 2,801 48.7% 12,015 66.2% 7,956 61.6%
Race/Ethnicity
 White 9,127 55.3% 17,858 64.0% 13,750 60.1%
 Black 3,071 14.1% 5,162 12.0% 3,905 12.3%
 Other2 1,734 10.8% 2,637 8.0% 2,253 9.1%
 Hispanic 4,975 19.7% 7,231 16.0% 6,506 18.5%
Total Family Income3
  Less than $10K 2,531 14.0% 4,873 12.2% 4,041 13.8%
  $10K to $24,999 3,463 19.8% 6,450 19.6% 5,489 21.6%
  $25K to $49,999 3,966 22.4% 7,028 22.6% 5,741 23.0%
  $50K to $99,999 4,110 25.5% 7,053 25.7% 5,375 24.4%
  $100K or more 3,247 18.4% 5,390 19.9% 3,848 17.2%
Census Region
  Northeast 2,964 18.2% 5,229 18.4% 4,163 18.6%
  Midwest 3,965 19.4% 7,393 21.1% 5,836 20.6%
  South 7,210 38.1% 12,463 37.1% 10,049 37.4%
  West 4,768 24.2% 7,803 23.4% 6,366 23.4%
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Data: Population Assessment of Tobacco and Health Study, Wave 1 Cohort (n=45,971)

1

The table excluded respondents with missing data on each variable

2

This category included non-Hispanic Asian, American Indian, Alaska Native, Native Hawaiian, other Pacific Islander, and those indicating more than one race.

3

Total family income for youth was not assessed until Wave 2. Youth total family income for Wave 1 was imputed based on their median values assessed across Waves 2–4.

Cigarette, E-Cigarette, and Any Cigar Initiation and Associations with Past-Year Blunt Use

Over the study period (3 years), we observed a greater proportion of people starting e-cigarettes (19.6%) than cigarettes (13.3%) or any cigar (12.2%; see Supplemental Figure S1). Around half of the people using blunts in the past year initiated cigarettes (46.1%), e-cigarettes (55.9%), or any cigar (50.4%; Figure 1). Meanwhile, people using non-blunt cannabis started these tobacco products at moderate rates (27.1%, 35.4%, and 17.7%, respectively). By contrast, those who used neither blunts nor cannabis at baseline initiated these tobacco products at the lowest rates (7.5%, 13.9%, and 6.8%, respectively). Thus, this evidence shows higher tobacco initiation related to past-year blunt use and, to a lesser extent, non-blunt cannabis use.

Figure 1.

Figure 1.

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Cumulative percentage of the PATH Study Wave 1 Cohort initiating cigarettes, e-cigarettes, and any cigar by past-year blunt use.

Our regression analyses confirmed a positive association between past-year blunt use and tobacco initiation, even after accounting for multiple possible confounders (Table 2). People who used blunts elevated their odds of starting cigarettes (OR = 4.5, 95% CI [3.6, 5.6]), as did those who used non-blunt cannabis (OR = 4.0, 95% CI [3.0, 5.3]) relative to those who used neither, and we did not observe differences in the odds of cigarette initiation between those who used blunts versus non-blunt cannabis. By contrast, the odds of initiating e-cigarettes and any cigar differed between blunts versus non-blunt cannabis. Those who smoked blunts were likelier to initiate e-cigarettes (OR = 3.7, 95% CI [3.2, 4.3]) than those who used non-blunt cannabis (OR = 2.8, 95% CI [2.4, 3.3]; adjusted Wald test: F[1,99] = 7.91; p = 0.006). People smoking blunts were also likelier to start smoking any cigar (OR = 6.7, 95% CI [5.6, 7.9]) than those who used non-blunt cannabis (OR = 2.2, 95% CI [1.7, 2.8]; adjusted Wald test: F[1,99] = 115.49; p < 0.001). We present unadjusted and complete adjusted model estimates in Supplemental Tables S2 and S3, respectively. Our data suggest that past-year blunt use is more strongly associated with starting to smoke any cigar than cigarettes or e-cigarettes.

Table 2.

Association Between Past-Year Blunt Use and Initiating Cigarettes, E-Cigarettes, and Any Cigar

Cigarettes1,3,4 E-Cigarettes1,2,4 Any Cigar1,2,3
OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value
Past-Year Blunt Use
  Neither (ref.) 1.0 1.0 1.0
  Non-Blunt Cannabis 4.0 (3.0, 5.3) <0.001 2.8 (2.4, 3.3) <0.001 2.2 (1.7, 2.8) <0.001
  Blunts 4.5 (3.6, 5.6) <0.001 3.7 (3.2, 4.3) <0.001 6.7 (5.6, 7.9) <0.001
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Data: Population Assessment of Tobacco and Health (PATH) Study Public Use Files (PUF), Waves 1–4

1

Model controlled for sex, age, race/ethnicity, annual family income, Census region, past-month other tobacco use, past-month alcohol use, past-month drug use, living with a tobacco user, and recent internalizing and externalizing problems

2

Model controlled for past-month cigarette use

3

Model controlled for past-month e-cigarette use

4

Model controlled for past-month traditional cigar, cigarillo, and filtered cigar use

To place these results in absolute terms, our models estimated that 2.6 million people in the US aged 12 years and older started smoking cigarettes over the study period (see Supplemental Table S4). About 13% (335,946) of these new initiates might be explained by past-year blunt smoking and 9.4% (242,878) by non-blunt cannabis. For 7.6 million e-cigarette initiates, 9.8% (741,993) and 10.8% (815,455) might be due to blunts and non-blunt cannabis, respectively. Lastly, there were about 3.6 million initiates of any cigars, with 15.4% (551,047) due to blunts and another 6.6% (235,948) from non-blunt cannabis. Our evidence indicates that blunt and non-blunt cannabis use may significantly contribute to the number of people who start tobacco.

Differences By Cigar Type: Traditional Cigars, Cigarillos, and Filtered Cigars

Considering the strong association between past-year blunt smoking and any cigar initiation, we explored differences by cigar type. We found most respondents had never used traditional cigars (75.8%), cigarillos (87.5%), or filtered cigars (87.5%) at baseline (data not shown in tables). Over the study period, more people had started smoking traditional cigars (11.0%) than cigarillos (9.1%) or filtered cigars (6.3%; Supplemental Figure S1). Those who used blunts in the past year initiated traditional cigars (35.0%), cigarillos (44.1%), and filtered cigars (23.5%) at higher rates than those using non-blunt cannabis (12.7%, 10.7%, and 6.5%, respectively) or neither (6.3%, 4.5%, and 3.3%, respectively; Figure 2). These findings indicate that past-year blunt smoking may be significantly related to starting to smoke cigarillos.

Figure 2.

Figure 2.

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Cumulative percentage of the PATH Study Wave 1 Cohort initiating traditional cigars, cigarillos, and filtered cigars by past-year blunt use.

Our regression results confirmed a strong association between past-year blunt smoking and cigarillo initiation (Table 3). People smoking blunts were much likelier to begin smoking cigarillos (OR = 6.5, 95% CI [5.5,7.8]) than non-blunt cannabis (OR = 1.8, 95% CI [1.4, 2.3]) or neither. By contrast, blunt and non-blunt cannabis use modestly increased the odds of starting traditional (ORs = 2.2 and 1.6, respectively) or filtered cigars (OR = 1.3 and 1.2, respectively). We present unadjusted estimates in Supplemental Table S5. These results suggest that the association between blunt use and initiating any cigars may be primarily due to cigarillos.

Table 3.

Association Between Past-Year Blunt Use and Initiating Traditional, Cigarillo, and Filtered Cigars

Traditional Cigars1,3,4 Cigarillos1,2,4 Filtered Cigars1,2,3
OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value
Past-Year Blunt Use
  Neither (ref.) 1.0 1.0 1.0
  Non-Blunt Cannabis 1.6 (1.2, 2.1) <0.001 1.8 (1.4, 2.3) <0.001 1.2 (0.9, 1.5) 0.284
  Blunts 2.2 (1.9, 2.7) <0.001 6.5 (5.5, 7.8) <0.001 1.3 (1.1, 1.6) 0.016
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Data: Population Assessment of Tobacco and Health (PATH) Study Public Use Files (PUF), Waves 1–4

1

Model controlled for sex, age, race/ethnicity, annual family income, Census region, past-month cigarette use, past-month e-cigarette use, past-month other tobacco use, past-month alcohol use, past-month drug use, living with a tobacco user, and recent internalizing and externalizing problems

2

Model controlled for past-month traditional cigar use

3

Model controlled for past-month cigarillo use

4

Model controlled for past-month filtered cigar use

Initiation of Combustible Tobacco or Any Three Tobacco Products Only

We next estimated the association between past-year blunt use and starting to use combustible tobacco (cigarettes or cigars), similar to Mayer et al. (2019), and starting any three of the tobacco products studied (cigarettes, e-cigarettes, or cigars). About one-third of respondents had never used a combustible product (34.2%) or any of the three tobacco products (33.6%; data not shown in tables). About 1-in-6 (17.6%) started using a combustible product, and almost a quarter (24.6%) started using any of the three products (Supplemental Figure S1). Almost two-thirds (63.0%) of people using blunts in the past year initiated a combustible product, while more than 3-in-4 (77.7%) initiated any tobacco (Figure 3). Comparatively, we observed lower rates for non-blunt cannabis use (34.8% and 54.3%, respectively) and neither (10.4% and 17.0%, respectively).

Figure 3.

Figure 3.

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Cumulative percentage of the PATH Study Wave 1 Cohort initiating any combustible tobacco (cigarettes or cigars) and any tobacco (cigarettes, e-cigarettes, or cigars) by past-year blunt use.

Our regression analyses corroborated these findings (Table 4). Past-year blunt smoking significantly elevated the odds of starting combustible products (OR = 9.0, 95% CI [7.6, 10.8]) or any of the three products (OR = 10.9, 95% CI [9.0, 13.1]) relative to modest associations with non-blunt cannabis use or our reference group of neither. We present unadjusted estimates in Supplemental Table S6. These findings demonstrate a stronger association between past-year blunt use and tobacco initiation.

Table 4.

Association Between Past-Year Blunt Use and Initiating Combustible Tobacco and Any Tobacco

Combustible Tobacco1,2,3 Any Tobacco1,2
OR 95% CI p-value OR 95% CI p-value
Past-Year Blunt Use
  Neither (ref.) 1.0 1.0
  Non-Blunt Cannabis 3.8 (3.0, 4.8) <0.001 4.5 (3.6, 5.5) <0.001
  Blunts 9.0 (7.6,10.8) <0.001 10.9 (9.0,13.1) <0.001
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Data: Population Assessment of Tobacco and Health (PATH) Study Public Use Files (PUF), Waves 1–4

1

Any tobacco included cigarettes, e-cigarettes, or cigars; Combustible tobacco included cigarettes or cigars

2

Model controlled for sex, age, race/ethnicity, annual family income, Census region, past-month other tobacco use, past-month alcohol use, past-month drug use, living with a tobacco user, and recent internalizing and externalizing problems

3

Model controlled for past-month e-cigarette use

Differences by Age, Race/Ethnicity, and Sex

Lastly, we explored effect modification by age, race/ethnicity, and sex by estimating the predicted probabilities of tobacco initiation (see Supplemental Figures S2–S10). For example, 15–17-year-olds who smoked blunts had a higher predicted probability of initiating cigarettes and e-cigarettes than 18–24-year-olds who smoked blunts, but these groups looked similar for starting any cigar (Figures S2–S4). Whites and Hispanics who smoked blunts had a higher probability of initiating cigarettes and e-cigarettes than Blacks. Still, Blacks who smoked blunts had the highest probability of starting any cigar (Figures S5–S7). Finally, males who smoked blunts had a higher probability of initiating e-cigarettes and any cigar than females who smoked blunts (Figures S9–S10).

Discussion

We had expected people who smoked blunts, which combine tobacco and cannabis, would elevate their risk of starting to use cigarettes, e-cigarettes, and cigars. Our data confirm this hypothesis. We find that people who smoked blunts in the past year are about four times likelier to start using cigarettes, three times likelier to start e-cigarettes, and six times likelier to start any cigar than people who did not smoke blunts or cannabis. These findings remained robust after accounting for possible confounders, such as sociodemographics, current use of other tobacco, alcohol, and drugs, living with a tobacco user, and internalizing and externalizing problems. Further, we observed stronger associations for initiating a combustible product (cigarettes or cigars) or any three of the tobacco products studied. This finding suggests residual confounding by past tobacco use may be insufficient to explain our results. Mayer and colleagues (2019) previously reported a two-fold association between lifetime blunt use and combustible tobacco product initiation one year later among youth in California and Connecticut. However, they did not find differences between blunt and non-blunt cannabis use. By contrast, we assessed more recent exposures, observed participants longer, and benefited from a larger, more nationally representative sample of youth and adults.

Our findings are consistent with a growing literature showing cannabis use as a risk factor for tobacco use, typically cigarettes – sometimes referred to as the “reverse gateway” theory (Agrawal et al., 2008; Badiani et al., 2015; Kristman-Valente et al., 2017; Patton et al., 2005). One explanation for the co-use of tobacco and cannabis is that people commonly inhale both, and such familiarity with one supports the use of the other (Agrawal & Lynskey, 2009). Co-use might also result from overlapping genetic and environmental factors, such as a predisposition for externalizing and drug use behaviors, peer influences, and availability (Agrawal et al., 2012). Additionally, exposure to blunts might have reduced people’s tobacco harm perception, produced nicotine cravings or withdrawal, or habituated individuals to the taste and effects of inhaling tobacco smoke. Qualitative studies also report the practice of blunt “chasing,” where a peer group passes around a blunt followed by a cigar or cigarette (Antognoli et al., 2018; Sifaneck et al., 2005). Therefore, social pressure and peer aspects could also play a unique role.

We observed differences in the risk of tobacco product initiation associated with blunt use. Blunt use was strongly associated with any cigar use, especially cigarillos. Cigarillos are a common choice for making blunts (Giovenco et al., 2016). People who smoke blunts might smoke cigars as a substitute when cannabis is unavailable or due to other legal or social restrictions (Antognoli et al., 2018). People also perceive blunts as less harmful than cigars and cigars as less harmful than cigarettes (Sinclair et al., 2013; Sterling et al., 2016); therefore, smoking blunts might serve as a gateway to other tobacco use, especially cigars.

Our finding that people who smoked blunts were likelier to start vaping e-cigarettes may be novel. Prior studies have reported the co-occurrence of e-cigarettes and cannabis (Simon et al., 2017; Wills et al., 2021) or that e-cigarette use increases the risk of using cannabis (Dai et al., 2018; Sun et al., 2022). People may perceive blunts and e-cigarettes as less harmful than cigarettes and cigars (Berg et al., 2014; Sterling et al., 2016). Therefore, health concerns might prompt those who smoke blunts to be more receptive to trying e-cigarettes when initiating another tobacco product. Additionally, studies find that e-cigarettes are an attractive choice for consuming tobacco in places where cigarettes are prohibited (Sapru et al., 2020). Devices that can vape nicotine and THC may be an attractive alternative to those who smoke blunts for similar reasons, but studies have not confirmed this.

Despite these findings, we acknowledge limitations when interpreting these results. First, the PATH Study does not ask people about other forms of mixing tobacco and cannabis in a single preparation, such as in joints (spliffs), pipes, or bongs, which could confound our estimates. However, consuming cannabis without tobacco in these forms appears to be the preferred method in the US (Hindocha et al., 2016). Second, we do not know whether these findings will generalize to populations outside the US or to other forms of tobacco and cannabis co-administration. Mixing tobacco and cannabis inside a joint is common in Europe and Australia and may contribute to cigarette smoking (Belanger et al., 2011; Patton et al., 2005). Third, the PATH Study at Wave 1 asked participants questions about their lifetime cigar use before questions about blunts. Some participants might interpret blunt smoking as cigar use even if they never smoked a cigar except as a blunt. Misclassification would have led to incorrectly excluding such participants. Finally, the past-year use of blunts and non-blunt cannabis is a relatively crude measure of exposure to cannabis and tobacco via blunts. We lacked data on recent use (e.g., past month) or frequency of use which might better inform tobacco initiation risk and may be an avenue for future studies.

Our findings have implications for the co-marketing of tobacco products and cannabis within an environment of liberalized cannabis laws, such as in the US. First, we should reconsider the co-marketing of tobacco and cannabis. For example, tobacco companies market flavored cigars and wraps that share the exact name as a strain of cannabis (e.g., Kush, Pineapple Express, and Purple Haze) and are sold cheaper than cigars without a cannabis-related flavor (Delnevo et al., 2019). Co-marketing is also more prevalent in school neighborhoods with a higher proportion of younger residents (Henriksen et al., 2018). In April 2022, the US Food and Drug Administration (FDA) proposed new rules prohibiting flavored cigar products (Food and Drug Administration, 2022). Should this rule be implemented and withstand legal challenges, it will be essential to determine whether cigar-using behaviors will change among those who primarily use them for smoking blunts. Second, the co-use of blunts and e-cigarettes warrants further attention. For example, an earlier studying using PATH Study data found that a quarter of cannabis-using young adults had used an ENDS device for cannabis consumption (Seaman et al., 2020). Another recent study using PATH Study data reported a strong association between adolescent e-cigarette use and prevalent cannabis use 1-year later (Sun et al., 2022). Therefore, using ENDS to co-use nicotine and cannabis could appeal to those who use co-use tobacco and cannabis via blunts or vice versa. Finally, most patients who developed e-cigarette or vaping use-associated lung injury (EVALI) in July 2019 used ENDS products containing cannabis e-liquid (Ghinai et al., 2019). Nearly all (96%) used prefilled cartridges or pods in either a universal vape pen or a proprietary nicotine-containing product (e.g., Juul). Therefore, safeguards may be needed to limit the modification of ENDS to vape cannabis e-liquid and restrict the sale of universal vape pens capable of vaping both substances to reduce their appeal to youth.

To conclude, people who smoke blunts are at a greater risk of starting cigarettes, e-cigarettes, and cigars. Blunts may contribute to an increased risk of initiating cigars and e-cigarettes above the risk due to cannabis alone. However, further study is needed to determine if the added risk is due to the co-administration of tobacco and cannabis from blunts or other social factors. Future studies should investigate the extent blunt smoking contributes to other tobacco endpoints, such as escalation to daily or regular use, dependence, and difficulty quitting.

Supplementary Material

1

Highlights.

  • Smoking blunts increased the risk of starting cigarettes, e-cigarettes, and cigars.

  • E-cigarette and cigar initiation greater for blunt vs. non-blunt cannabis use.

  • Associations stronger for initiating any tobacco and combustible use.

  • Association between blunts and cigar initiation strongest for cigarillos.

  • Youth smoking blunts had higher odds of starting cigarettes and e-cigarettes.

Acknowledgments

We thank the following colleagues for their feedback and support: Dr. Daniela Marshall, Dr. Marushka L. Silveria, Dr. Colm Everard, Dr. Melisa R. Creamer, and Ms. Kellie Washington.

Funding:

Dr. Fairman is supported in part by a seed grant from the Vice Chancellor for Research and Innovation at UAMS. The PATH Study was supported with Federal funds from the National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), and the Center for Tobacco Products (CTP), Food and Drug Administration (FDA), Department of Health and Human Services, under contract to Westat (contract nos. HHSN271201100027C and HHSN271201600001C), and through an interagency agreement between NIH NIDA and FDA CTP. Heather L. Kimmel, Carlos Blanco, and Wilson M. Compton were substantially involved in the scientific management of and providing scientific expertise for contract nos. HHSN271201100027C and HHSN271201600001C.

Footnotes

Author Disclosures

Conflict of Interest

Compton reports long-term stock holdings in Pfizer Incorporate, General Electric Company, and 3M Companies unrelated to this manuscript. Other authors have no conflicts of interest to declare.

Disclosures: Compton reports long-term stock holdings in Pfizer Incorporate, General Electric Company, and 3M Companies unrelated to this manuscript. Other authors have no conflicts of interest to declare.

Disclaimers: The views and opinions expressed in this manuscript are those of the authors only and do not necessarily represent the views, official policy, or position of the US Department of Health and Human Services or any affiliated institutions or agencies.

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