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. 2023 Mar 25;33:102190. doi: 10.1016/j.pmedr.2023.102190

Association of dual electronic cigarettes and marijuana use with sleep duration among adults from the United States, NHANES 2015–2018

Zhenzhen Pan 1,1, Qian Wang 1,1, Yun Guo 1, Shidi Xu 1, Shanshan Pan 1, Shiyao Xu 1, Qin Zhou 1, Ling Li 1,⁎
PMCID: PMC10201852  PMID: 37223560

Abstract

Electronic cigarette (e-cigarette) use is becoming more widespread, and studies show that they are not absolutely harmless. To investigate the association between the dual use of e-cigarettes and marijuana with sleep duration among adults in the United States, this cross-sectional study used data from 6,573 participants aged 18–64 years from 2015 to 2018 from the National Health and Nutrition Examination Survey database. Chi-square tests and analysis of variance were used for bivariate analyses of binary and continuous variables, respectively. Multinomial logistic regression models were used for univariate and multivariate analyses of e-cigarette use, marijuana use, and sleep duration. Sensitivity analyses were conducted in populations with dual e-cigarette and traditional cigarette use and dual marijuana and traditional cigarette use. People who concurrently use e-cigarettes and marijuana had higher odds of not having the recommended sleep duration than neither users (short sleep duration: odds ratio [OR], 2.34; 95% confidence interval [CI], 1.19–4.61; P = 0.014; long sleep duration: OR, 2.09; 95% CI, 1.53–2.87; P < 0.001) and a shorter sleep duration than e-cigarette only users (OR, 4.24; 95% CI, 1.75–4.60; P < 0.001). Concurrent traditional cigarette and marijuana users had higher odds of long sleep duration than neither users (OR, 1.98; 95% CI, 1.21–3.24; P = 0.0065). Almost half of the people who concurrently use e-cigarettes and marijuana had both short and long sleep durations compared to neither users and short sleep duration compared to e-cigarette only users. Longitudinal randomized controlled trials are needed to explore the joint effect of dual tobacco use on sleep health.

Keywords: E-cigarette, Tobacco, Marijuana, Dual use, National Health and Nutrition Examination Survey, Sleep

1. Introduction

Sleep disturbances have been a public health issue for years. However, the problem has plagued nearly a quarter of the world’s population and has become a subject of greater concern in recent years (Irish et al., 2015, Brown et al., 2018, Laver et al., 2020; Miner and Kryger, 2017). These disturbances include sleep apnea, insomnia, restless leg syndrome, sleepwalking, and poor sleep quality, which may all lead to abnormal sleep duration (Chokroverty, 2010, Janson et al., 1995). According to the National Sleep Foundation, the recommended sleep duration for people aged 18–64 years is 7–9 h. Babies, young children, and teens need even more sleep to enable their growth and development. People over 65 years also require 7–8 h of sleep per night (Hirshkowitz et al., 2015).

Smoking cigarettes has been heavily implicated as the cause of common sleep problems (Cohrs et al., 2014, Wetter and Young, 1994, Deleanu et al., 2016, Jaehne et al., 2012, Liu et al., 2013, McNamara et al., 2014, Liao et al., 2019, Hsu et al., 2019, Bogati et al., 2020, Nuñez et al., 2021) and has also been reported to be associated with sleep duration (Chang et al., 2018, Yang et al., 2018), which itself is a risk factor for chronic conditions such as obesity, depression, diabetes, and cardiovascular diseases (CVD) (Gangwisch et al., 2006). These chronic conditions can also lead to poor sleep quality (Gangwisch et al., 2007, Pilcher and Huffcutt, 1996, Wilson and Argyropoulos, 2005, Yaggi et al., 2005, Lavigne et al., 1997) and are likely to be exacerbated by cigarette smoking (Levy et al., 2017). An increasing number of people, especially young adults, currently prefer electronic nicotine delivery systems or e-cigarettes over traditional cigarettes. A nationwide study in the United States (U.S.) examined the characteristics of individuals who used e-cigarettes (McConnell et al., 2017), and the results showed that 27% of former e-cigarette users still use e-cigarettes, and 45.3% of these used e-cigarettes regularly (≥20 days per month). E-cigarettes are widely promoted as a safer alternative to smoking (Gay et al., 2020). However, an increasing number of studies have shown that e-cigarettes are not harmless (Rohde et al., 2020; Russell and Cevik, 2020b) and are also reported to be associated with sleep health (Marques et al., 2021, Wiener et al., 2020, Riehm et al., 2019, Kianersi et al., 2021, Brett et al., 2020, Merianos et al., 2021, Lee and Lee, 2021, Monti and Pandi-Perumal, 2022). Similar concerns have been raised regarding the use of marijuana, which is also popular among young Americans. The use of cannabinoids is a double-edged sword because they have both adverse and therapeutic properties (Lavender et al., 2022, Shannon et al., 2019, Kaul et al., 2021, Choi et al., 2020, Mondino et al., 2021, Kolla et al., 2022). Evidence shows that chronic cannabis administration could disrupt circadian rhythms and reduce the duration of the deepest phase (stage N3) of non-rapid eye movement sleep (Vaseghi et al., 2021). However, the effects of cannabinoids on the sleep-wake cycle are inconsistent (Maultsby et al., 2021, Chen et al., 2020). Given the high rate of cannabis use among Americans, it is especially important to study its effect as well as the joint effect of cigarettes on sleep health. Therefore, this study was conducted to observe the association between sleep duration and dual use of e-cigarettes and marijuana in a U.S. population with a large age range (18–64 years) representative of young adults and adults.

2. Participants and methods

2.1. Study population

The data in this study were obtained from the National Health and Nutrition Examination Survey (NHANES) 2015–2018 cycle, which contains data on both cigarette and marijuana use and sleep duration. NHANES is a cross-sectional nationwide survey in which participants are selected using a stratified multistage probability design and is thus representative of the U.S. population. NHANES is unique because it combines interviews and physical examinations. The interviews included demographic, dietary, and health-related questions. The examination component consisted of medical, dental, and physiological measurements as well as laboratory tests administered by highly trained medical personnel (Goodhines et al., 2019) (more details via https://www.cdc.gov/nchs/nhanes.htm). Fig. 1 shows the flowchart for the selection of the study participants. Adults aged 18–64 years who participated in the 2015–2018 NHANES surveys and had complete data on sleep duration, e-cigarette use, and marijuana use were included in the analysis. This study was approved by the National Center for Health Statistics Research Ethics Review Board. The approval number is Continuation of Protocol #2011–17 for the 2015–2018 cycle.

Fig. 1.

Fig. 1

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Flowchart for the selection of study participants in the current analysis. NHANES, National Health and Nutrition Examination Survey.

2.2. Study procedure

Dependent variable: Sleep duration.

Sleep duration was assessed through household interviews using a computer-assisted personal interviewing system. Participants were asked the following question: “How much sleep (in hours) do you usually get at night, on weekdays or workdays?” According to the National Sleep Foundation’s recommended sleep duration for people aged 18–64 years, we categorized weekday sleep duration as <7, 7–9 h (reference group), and >9 h per night, which we defined as short, normal, and long sleep durations, respectively.

Independent variables: E-cigarette and marijuana use was categorized as neither use of e-cigarette nor marijuana, e-cigarette use only, marijuana use only, and dual e-cigarette and marijuana use.

E-cigarette users were asked the following questions: “Have you ever used an e-cigarette, even once?” and “During the past 30 days, on how many days did you use e-cigarettes?” Participants who had not used an e-cigarette even once were defined as “never users,” those who had used e-cigarettes before but had not used them in the last 30 days were defined as “former users,” whereas those who had used e-cigarettes in the last 30 days were termed as “current users.”

Marijuana users were defined using the following questions: “Have you ever, even once, used marijuana or hashish?” and “How long has it been since you last used marijuana or hashish?” Participants who had not used marijuana or hashish even once were defined as “never users,” those who had used marijuana or hashish before but had not in the last 30 days were defined as “former users,” whereas those who had used marijuana or hashish in the last 30 days were termed as “current users.”

“Dual e-cigarette and marijuana users” refer to participants who had used both e-cigarettes and marijuana in the last 30 days. Participants who did not use e-cigarettes or marijuana in the last 30 days were defined as “neither users;” “e-cigarette only users” were those who used e-cigarettes but not marijuana, whereas “marijuana only users” were participants who had used marijuana but not e-cigarettes in the last 30 days.

Traditional cigarette users were asked the following questions: “Have you smoked at least 100 cigarettes in your entire life?” and “Do you currently smoke cigarettes?” Participants who had not smoked at least 100 cigarettes in their entire lives were “never users.” Participants who had smoked at least 100 cigarettes in their lives but did not smoke now were defined as “former users,” while those who still smoked were “current users.”

Covariate variables: Age, sex, race, annual household income, being overweight/obese, education level, marriage status, occupation, depression (Patient Health Questionnaire [PHQ] score), serum cotinine level, chronic diseases (including diabetes, CVD, and asthma), and snoring or difficulty in breathing.

Being overweight/obese was defined as a body mass index ≥25. Snoring or difficulty in breathing was a symptom of sleep disorders. Participants were asked the following questions: “In the past 12 months, how often did {you/Survey participants} snort, gasp, or stop breathing while {you were} asleep?” Individuals were categorized as “never,” “1–4 nights/week,” or “≥5 nights/week,” according to the frequency. Depression severity was calculated using the PHQ score, with a PHQ score < 10 classified as minimal to mild depression, 10–14 as moderate depression, and ≥15 as severe depression. Chronic diseases such as diabetes, CVD, and asthma, which can also affect sleep duration, were also considered (Liu et al., 2013, Levy et al., 2017, McConnell et al., 2017, Gay et al., 2020, Rohde et al., 2020, Russell et al., 2020a, Marques et al., 2021).

2.3. Statistical analysis

Chi-square tests and analysis of variance were used for bivariate analyses of binary and continuous variables, respectively. Multinomial logistic regression models were used for univariate and multivariate analyses of e-cigarette, marijuana use, and sleep duration. Variables in the final model were selected according to the results of the univariate analysis. All multivariable models were adjusted for age, sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American, other Hispanic, and others), annual household income (<$20,000 vs. ≥$20,000), being overweight/obese, serum cotinine level, cigarette use (current user and former user vs. never user), education level (more than high school and high school graduate vs. less than high school), marriage status (married/living together and divorced/separated vs. widowed/never married), severity of depression (severe and moderate depression vs. minimal to mild depression), occupation (with a job vs. jobless/looking for a job), snoring or difficulty in breathing (frequently, occasionally, and rarely vs. never), and chronic diseases (yes vs. no). A two-tailed P value < 0.05 indicated a statistically significant difference. The R Program version 3.6.2 (The R Foundation for Statistical Computer, Vienna, Austria; https://www.r-project.org) was used for all analyses.

3. Results

3.1. Proportion of e-cigarette dual use

The main characteristics of the 6,573 study participants are shown in Table 1. Of all the participants, 80.77% were aged 26–64 years, while the rest were aged 18–25 years; 75.20% had normal sleep duration, 16.02% had short sleep duration, and 8.78% had long sleep duration. We also found that 20.39% of the participants were former e-cigarette users, 7.71% were current e-cigarette users (data not presented), 28.58% were current marijuana users, 4.23% concurrently used e-cigarette and marijuana, 4.01% used both e-cigarette and traditional cigarette, and 9.27% used marijuana and traditional cigarette concurrently (Table 1 and Table A.1). Additionally, among those who did not have the recommended sleep duration, 43.8% were people who concurrently used e-cigarette and marijuana (data not presented). The number of participants who used both e-cigarettes and marijuana increased over time (Fig. 2).

Table 1.

Main characteristics of all participants (n = 6,573), NHANES 2015–2018, 18–64 years.

Number Weighted percentage
Age
 18-25y 1,375 19.23
 26-64y 5,198 80.77
Sex
 Female 3,416 50.17
 Male 3,157 49.83
Race
 Non-Hispanic White 2,032 59.52
 Mexican American 1,142 10.97
 Other Hispanic 704 7.45
 Non-Hispanic black 1,473 12.00
 Other 1,222 10.07
Annual household income<$20,000 1,511 11.58
Overweight/obese,yes 4,576 70.16
E-cigarette - marijuana use
 Neither use 4,592 67.93
 E-cigarette use only 208 3.48
 Marijuana use only 1,501 24.36
 Dual use 272 4.23
Traditional cigarette use
 Never use 4,175 60.25
 former use 1,052 19.78
 Current use 1,344 19.97
Education level
 Less than high school 1,209 12.02
 High school graduate 1,603 24.30
 More than high school 3,760 63.68
Marriage status
 Windowed/never married 1,628 25.02
 Divorced/separated 759 11.38
 Married/living together 3,698 63.60
Occupation
 No job/looking for a job 1,817 22.10
 Already have a job 4,749 77.90
Depression (PHQ score)
 Minimal to mild 6,130 93.80
 Moderate 290 4.37
 Severe 142 1.83
Chronic diseases, yes 1,189 0.19
Snort or stop breathing
 Never 4,768 75.98
 1–4 nights/week 1,207 19.49
 5 or more nights/week 3,12 4.53
Sleep duration
 <7h 1,186 16.02
 7–9 h 4,667 75.20
 >9h 720 8.78
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The numbers may vary because of missing data. We have missing data on traditional cigarette use, education level, marriage status, occupation, depression and snort or stop breathing.

Chronic diseases include cardiovascular diseases, asthma and diabetes. PHQ: Patient health questionnaire.

Fig. 2.

Fig. 2

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Number of participants with dual use of tobacco products and marijuana in different cycles (2015–2016 and 2017–2018).

3.2. Participants’ characteristics

Compared to participants with normal sleep duration, those with short sleep duration were more likely to be people who currently used traditional cigarettes or concurrently used tobacco products (Table 2 and Table A.2). Meanwhile, they were also more likely to be older, male, overweight/obese, non-Hispanic black, other Hispanic, widowed or divorced, and frequent snorers or with sleep apnea, to have an education level less than high school or be a high school graduate, have no job or be looking for a job, be moderate to severely depressed, and have an annual household income <$20,000, chronic diseases, and higher serum cotinine level. Participants with long sleep duration yielded similar results, except that they were more likely to be younger, female, not overweight/obese, but not snoring or having difficulty breathing at night (Table 2).

Table 2.

Main characteristics stratified by sleep duration and the findings regarding sleep duration and electronic cigarette-marijuana dual use, NHANES 2015–2018, 18–64 years (n = 6,573).

Sleep duration
 P-value
Short (<7h)
(n = 1,186)		 Normal (7–9 h)
(n = 4,667)		 Long (>9h)
(n = 720)
Age, y 40.79 ± 0.46 38.82 ± 0.29 33.82 ± 0.64 <0.001***
Sex <0.001***
 Female 518(40.60) 2,462(51.00) 436(60.47)
 Male 668 (59.40) 2,205 (49.00) 284 (39.53)
Race <0.001***
 Non-Hispanic White 282 (49.88) 1,534 (62.52) 216 (51.41)
 Mexican American 175 (11.01) 833 (10.60) 134 (14.05)
 Other Hispanic 141 (9.62) 487 (6.91) 76 (8.04)
 Non-Hispanic black 409 (20.75) 886 (9.61) 178 (16.48)
 Other 179 (8.74) 927 (10.36) 116 (10.02)
Annual household income <$20,000 279 (12.17) 999 (9.84) 233 (25.39) <0.001***
Overweight/obese, yes 898 (75.04) 3,229 (69.60) 449 (65.99) <0.001***
E-cigarette-marijuana use <0.001***
 Neither use 797 (63.57) 3,335 (69.90) 460 (59.07)
 E-cigarette use only 37 (3.16) 141 (3.41) 30 (4.69)
 Marijuana use only 283 (26.13) 1,037 (23.41) 181 (29.24)
 Dual use 69 (7.14) 154 (3.28) 49 (7.00)
Traditional cigarette use <0.001***
 Never use 671 (50.59) 3,050 (62.44) 454 (59.10)
 former use 187 (20.07) 782 (20.52) 83 (12.98)
 Current use 328 (29.34) 833 (17.04) 183 (27.92)
Serum cotinine, μg/mL 0.094 ± 0.0070 0.052 ± 0.0039 0.067 ± 0.0073 <0.001***
Education level <0.001***
 Less than high school 237 (15.05) 789 (10.20) 183 (22.12)
 High school graduate 315 (30.06) 1,047 (21.75) 241 (35.63)
 More than high school 634 (54.89) 2,830 (68.05) 296 (42.25)
Marriage status <0.001***
 Windowed/never married 306 (24.80) 1,108 (23.95) 214 (35.54)
 Divorced/separated 165 (13.52) 513 (10.66) 81 (13.82)
 Married/living together 665 (61.68) 2,734 (65.39) 299 (50.64)
Occupation <0.001***
 No job/looking for a job 278 (20.28) 1152(19.04) 387 (51.62)
 Already have a job 908 (79.72) 3509(80.96) 332(48.38)
Snort or stop breathing <0.001***
 Never 791 (69.63) 3,440 (77.21) 537 (76.78)
 1–4 nights/week 235 (22.94) 838 (18.77) 134 (19.44)
 5 or more nights/week 92(7.43) 197 (4.02) 23 (3.78)
Depression severity (PHQ score) <0.001***
 Minimal to mild 1,077 (90.36) 4,413(95.01) 640 (89.75)
 Moderate 68 (6.20) 173(3.71) 49 (6.63)
 Severe 39 (3.44) 74(1.28) 29 (3.62)
Chronic diseases 0.0018**
 No 814 (78.93) 3,357 (82.73) 410 (74.41)
 Yes 261 (21.07) 766 (17.27) 162 (25.59)
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*P < 0.05, **P < 0.01, ***P < 0.001.

Values are presented as numbers (%) or mean (mean ± standard deviation).

The numbers may vary because of missing data. We have missing data on traditional cigarette use, education level, marriage status, occupation, depression and snort or stop breathing.

Chronic diseases include cardiovascular diseases, asthma and diabetes. PHQ: Patient health questionnaire.

3.3. Association between e-cigarette dual use and sleep duration

We found that current marijuana only users had a significant 1.49 times higher odds of long sleep duration than neither users (Table 3). People who currently used both e-cigarettes and marijuana had 2.26-fold higher odds of short sleep duration and 2.56-fold higher odds of long sleep duration than those who were currently using neither e-cigarettes nor marijuana. Similar results were observed when analyzing the association between dual e-cigarette and traditional cigarette use or traditional cigarette and marijuana use and sleep duration (Tables A.3 and A.4). Meanwhile, people who currently used only traditional cigarettes had significantly higher odds of both short and long sleep duration than neither users. After adjusting for confounders (including age, sex, race, annual household income, overweight/obese, smoking status, cotinine level, education level, marital status, occupation, depression severity, snoring or difficulty in breathing, and chronic diseases), those who dual use e-cigarette and marijuana had 2.34- and 2.09-fold significantly higher odds than neither users in the groups with short and long sleep durations, respectively. They also had a significant 4.24-fold higher odds of having short sleep duration than those who used only e-cigarettes (Table 4). We also found that people with concurrent traditional cigarette and marijuana use had a significant 1.98-fold higher odds of having long sleep duration than neither users (Table A.5). However, no significant differences were observed between dual e-cigarette and traditional cigarette use and sleep duration (Table A.6).

Table 3.

Association between sleep duration and dual use of e-cigarette and marijuana, NHANES 2015–2018, 18–64 years (n = 6,573, univariate).

 Sleep duration
Short (<7h) (n = 1,186)
 Normal (7–9 h)
(n = 4,667)
 Long (>9h) (n = 720)
OR (95% CI) P-value OR (95% CI) P-value
E-cigarette - marijuana use Ref.
 E-cigarette only vs. neither 1.06 (0.65, 1,75) 0.80 1.60 (0.68, 3.73) 0.28
 Marijuana only vs. neither 1.20 (0.88, 1.64) 0.24 1.49 (1.27, 1.75) <0.001***
 Dual vs. neither 2.26 (1.47, 3.47) <0.001*** 2.56 (1.95, 3.35) <0.001***
 Marijuana only vs. e-cigarette only 1.15 (0.64, 2.07) 0.64 0.91 (0.43, 1.92) 0.80
 Dual vs. E-cigarette only 2.14 (1.45, 3.14) <0.001*** 1.57 (0.72, 3.44) 0.26
 Dual vs. marijuana only 1.86 (1.10, 3.14) 0.021 1.73 (1.35, 2.24) <0.001***
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*P < 0.05, **P < 0.01, ***P < 0.001.

The models were all unadjusted.

Table 4.

Association between sleep duration and dual use of e-cigarette and marijuana, NHANES 2015–2018, 18–64 years (n = 6,573, multivariate).

Sleep duration
Short (<7h) (n = 1,186)
 Normal (7–9 h) (n = 4,667)
 Long (>9h) (n = 720)
OR (95% CI) P-value OR (95% CI) P-value
E-cigarette - marijuana use Ref.
 E-cigarette only vs. neither 0.85 (0.45, 1.59) 0.61 0.85 (0.29, 2.44) 0.76
 Marijuana only vs. neither 1.12 (0.78, 1.61) 0.53 1.46 (0.95, 2.25) 0.08
 Dual vs. neither 2.34 (1.19, 4.61) 0.014* 2.09 (1.53, 2.87) <0.001***
 Marijuana only vs. e-cigarette only 0.84 (0.67, 2.77) 0.40 0.99 (0.61, 4.73) 0.32
 Dual vs. E-cigarette only 4.24 (1.75, 4.60) <0.001*** 1.67 (0.86, 6.68) 0.095
 Dual vs. marijuana only 1.88 (0.97, 4.51) 0.060 1.20 (0.80, 2.53) 0.23
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*P < 0.05, **P < 0.01, ***P < 0.001.

The models were all adjusted for age, sex, race, annual household income, overweight/obese, smoking status (traditional cigarette), cotinine level, education level, marital status, occupation, depression severity, snort or stop breathing, and chronic diseases.

OR: Odds ratio. CI: Confidence interval.

4. Discussion

As sleep health is attracting more attention, the objective of the current study was to investigate whether e-cigarette and marijuana dual use was associated with sleep duration among adults. In this cross-sectional survey study of 6,573 participants aged 18–64 years in the U.S., 24.80% had short or long sleep duration according to National Sleep Foundation (Hirshkowitz et al., 2015). Meanwhile, 3.48% of the participants used only e-cigarettes currently, 24.36% used only marijuana currently, 4.23% used both e-cigarettes and marijuana, 4.01% used e-cigarettes and traditional cigarettes concurrently, and 9.27% used both marijuana and traditional cigarette. We also found that former or current e-cigarette use, current marijuana use, current dual e-cigarette and marijuana use, and current traditional cigarette use were more likely to be associated with a non-recommended sleep duration.

Prior studies have reported that e-cigarette use was associated with worse sleep health, especially among the youth (Brett et al., 2020, Riehm et al., 2019, Kianersi et al., 2021). Wiener RC et al. reported that participants who currently used e-cigarettes were 1.82-fold more likely not to get their recommended sleep duration compared with participants who never used e-cigarettes (Riehm et al., 2019). Other studies have found that co-users of e-cigarettes with other tobacco products may have more emotional problems and experience more harm than e-cigarette-only users (Kang and Bae, 2021, Abafalvi et al., 2019, Lee and Lee, 2019, Berlin et al., 2019, Advani et al., 2022). Kang and Bae (2021) conducted a study to examine between-groups differences in depression and sleep quality based on smoking/vaping status among Korean adults and showed that dual users of e-cigarettes and traditional cigarettes had significantly higher depression scores (PHQ-9) and significantly lower sleep quality (Pittsburgh Sleep Quality Index-Korean version), respectively, than did cigarette users and non-users. Abafalvi et al. (2019) reported that dual users of e-cigarettes and traditional cigarettes were significantly more likely to report adverse effects of vaping than e-cigarette-only users (26.2% vs. 11.8%, P < 0.001). Lee and Lee (2019) were the first to report that dual users of e-cigarettes and traditional cigarettes had a higher prevalence of depression and suicidal tendencies among South Korean adolescents. Berlin et al. (2019) found that dual users of e-cigarettes and traditional cigarettes in France may have higher overall nicotine intake than exclusive e-cigarette users, but they may take in less nicotine from their e-cigarettes. A study conducted by Advani et al. (2022) demonstrated that dual use of e-cigarettes and traditional cigarettes was associated with longer sleep latency, and the shared component of nicotine may be a driver. However, to date, there are no studies on the relationship between e-cigarette and cannabis co-use and sleep health in such a large age group.

Marijuana use has been reported to be associated with either a short or long sleep duration in previous studies (Babson et al., 2017, Bhagavan et al., 2020, Pupko, 2018, Schwenk et al., 2022) and is sometimes perceived as providing benefits as a sleep aid (Goodhines et al., 2019, Doremus et al., 2019, Diep et al., 2022, Drazdowski et al., 2021), which served as a double-edged sword. Schwenk et al. found that recent cannabis users had greater adjusted odds of reporting both short and long sleep. Heavy users, those who were using cannabis for at least 20 of the past 30 days, were even more likely to report sleep durations at the extreme ends of the range (Schwenk et al., 2022). From a sample representing approximately 146 million adults in the U.S., recent cannabis use was associated with the extremes of nightly sleep duration, with suggestions of a dose–response relationship (Diep et al., 2022). In our study, we did not observe a significant association between marijuana or e-cigarette single use and short or long sleep duration. However, there was a significant association between dual e-cigarette and marijuana use and both short and long sleep duration. Compared to e-cigarette only use, dual use had 4.24-fold higher odds of short sleep duration. Meanwhile, compared to neither use, dual use had 2.34-fold higher odds of short sleep duration and 2.09-fold higher odds of long sleep duration. The results indicate that people with dual e-cigarette and marijuana use are more likely to have short sleep duration than single tobacco users, and both had a sleep duration that is not recommended when compared to neither users. We also found that current use of traditional cigarettes was significantly associated with a sleep duration that is not recommended (both short and long), but there was no significant association between dual e-cigarette and traditional cigarette use with the recommended sleep duration. We posit that it might be because of the decline in the use of traditional cigarettes when also using e-cigarettes.

5. Limitations

This study has some limitations. First, we lacked data on weekend sleep duration, which prevented us from analyzing the effects of tobacco exposure on weekday and weekend sleep duration separately and exploring the differences. Second, we lacked data on sleep behavior and polysomnography parameters, which would describe the affected sleep conditions in more detail. Third, because all interview data were collected by questionnaires, such as smoking status, recall bias could not be avoided. Finally, although our study suggests that dual e-cigarette and marijuana use was associated with a sleep duration that is outside of the recommended range, we still could not confirm a causal association between them.

6. Conclusion

In conclusion, our study suggests that almost half of the people who concurrently used e-cigarettes and marijuana had a non-recommended sleep duration. Dual use of e-cigarettes and marijuana was associated with both short and long sleep duration compared to neither use and short sleep duration compared to e-cigarette only use. Future longitudinal randomized controlled trials are needed to explore the joint effect of dual tobacco and marijuana use on human sleep health.

Funding

This study was supported by the Medical Innovation Team of Jiangsu Province [grant no. CXTDB 2017016]; the Major Program of Wuxi Health and Family Planning Commission [grant no. Z202016]; Wuxi Medical Talents [grant no. QNRC071]; the Youth Project of Wuxi Health and Family Planning Commission [grant no. Q201837]; the Top Talent Support Program for young and middle-aged people of the Wuxi Health Committee [grant no. HB2020088], and Maternal and child health project of Wuxi Health Commission [grant number FYKY202204].

CRediT authorship contribution statement

Zhenzhen Pan: Data curation, Writing – original draft. Qian Wang: Data curation, Validation. Yun Guo: Investigation, Visualization. Shidi Xu: Investigation, Visualization. Shanshan Pan: Data curation, Validation. Shiyao Xu: Writing – review & editing. Qin Zhou: Writing – review & editing. Ling Li: Conceptualization, Methodology, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We would like to thank the Government of Jiangsu Province and Medical Innovation Team of Jiangsu Province and Wuxi Municipal Bureau on Science and Technology for their financial support. We would like to thank Wei Chen and Yueh-ying Han from the Division of Pediatric Pulmonary Medicine, UPMC Children’s Hospital of Pittsburgh for directing the research design. We would like to thank Ying Ding and Tao Sun of Biostatistics, Public Health, University of Pittsburgh for directing the statistics of this research. We would like to thank Editage (www.editage.cn) for English language editing.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2023.102190.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Supplementary data 1
mmc1.docx (34.9KB, docx)

Data availability

Data will be made available on request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary data 1
mmc1.docx (34.9KB, docx)

Data Availability Statement

Data will be made available on request.

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