Abstract
Introduction
Polysubstance use—use of more than one substance—is prevalent and an emergent public health issue. Yet not much is known about factors associated with same-day polysubstance use among adolescents. This study examined correlates of same-day tobacco and cannabis use/co-use among adolescents who use tobacco/cannabis.
Methods
Cross-sectional data were from 10th and 11th grade students (n = 536) who reported tobacco/cannabis use. Regression models were used to examine intrapersonal, psychological (anxiety, depression), societal (societal concern, discrimination), and environmental (public and home secondhand smoke/vape exposure) correlates of past 30-day usage frequency (no, infrequent, and frequent use) of same-day: poly-product use (poly-tobacco/nicotine [use of different types of nicotine/tobacco]; poly-cannabis [use of different types of or marijuana/tetrahydrocannabinol (THC)]); poly-drug use [tobacco/nicotine and marijuana/THC], and nicotine and THC vape mixing.
Results
Participants were predominantly Hispanic (66.23%) and male (62.50%). Among participants, 8.58%, reported frequent same-day poly-tobacco use, 13.81% frequent same-day poly-cannabis use, 13.25% frequent same-day poly-drug use, and 3.36% vape mixing. Past 30-day alcohol use was associated with higher odds (1.88–8.31, p<.05) of infrequent and frequent same day use of all study outcomes except vape mixing. Secondhand smoke/vapor exposure was consistently associated with higher odds (1.13–1.26, p < .05) of infrequent/frequent same day use. Discrimination increased the odds of some same-day polysubstance use while societal concerns had inconsistent effects across study outcomes.
Conclusion
A significant proportion of adolescents who use tobacco/cannabis products might engage in high-risk use patterns. Alcohol use, societal, and environmental factors significantly increase the likelihood of same-day poly-use of tobacco and cannabis products.
Implications
Frequent same-day poly-product/drug use is common among adolescents who use tobacco and/or cannabis. Alcohol use, societal concerns, and environmental exposure to secondhand smoke/vape are significant contributors to same-day poly-product/drug use and nicotine and marijuana/THC vape mixing among these adolescents. Findings suggest that while infrequent same-day poly-product/drug use may be more opportunistic and situation-dependent, often occurring in contexts where alcohol is present, frequent use may be more influenced by social contexts and environmental cues. Understanding these complex relationships between substances and high-risk use patterns is crucial for developing effective prevention strategies and treatment approaches for poly-drug use disorders.
Introduction
Tobacco and cannabis are among the most widely used substances among adolescents in the United States (U.S.),1 and use of multiple tobacco/cannabis products, and poly-drug use of tobacco and cannabis products are predominant use patterns.2–4 In 2019, 34% and 14% of high school students reported lifetime and past 30-day use of both cannabis with e-cigarettes and/or combustible tobacco, respectively.5,6 With the development of various new tobacco/nicotine products, recent cannabis legislative reforms, and diverse cannabis product landscape, poly-product use (ie, poly-tobacco/nicotine [use of different types of nicotine/tobacco products], poly-cannabis [use of different types of or marijuana/THC] products) and poly-drug use/co-use (use of both tobacco and cannabis products eg, nicotine and THC vape mixing) is an emergent public health concern7 contributing to the burden of mental health problems and addiction in the U.S.4,8
Polysubstance use is a complex behavior that is difficult to conceptualize in research studies given the wide array of substances involved, heterogeneity in co-use timeframes (ie, same day, past 30-day, 6-month, 12-month co-/poly-use), large number of drug combinations of varying quantity, frequency, and mode of administration, and lack of diagnostic specificity as a result of the variability in polysubstance use patterns.4,9–11 Despite this complexity, polysubstance use (and broadly, combined use of multiple drugs/substances) is problematic and considered a high-risk behavior given its association with increased risk of overdose, substance dependence, toxicant exposure, and adverse health outcomes including psychiatric problems such as anxiety and depression.2,11–16
The temporal proximity of polysubstance use patterns (ie, same-month different-day use, same-day co-administration, same-day different-occasion use) plays an important role in shaping its health effects and consequences.11,17 Same-day poly-product and poly-drug use/co-use is a polysubstance use pattern among adolescents that is particularly problematic due to its strong association with persistent substance use disorders, mental health challenges, and negative life outcomes that often extend into adulthood.14,16,18,19 Yet, the drivers of this problematic polysubstance use pattern among adolescents are unclear.2,20,21 These higher-risk use patterns (ie, same-day polysubstance use) are particularly concerning because of the greater likelihood of engendering more immediate and severe health risks, such as overdose or impaired judgment.14
Several theoretical perspectives, such as the ecological framework,22 have demonstrated that dynamic intrapersonal, interpersonal, biological, and psychological systems interact with contextual factors such as the environment (social and physical) to shape health and risk behaviors.23 Therefore, to identify the drivers of these high-risk use patterns, employing an ecological perspective22 that examines the intrapersonal, psychosocial, and environmental (societal and physical) factors related to poly-product use/co-use among adolescents is an important starting point, particularly given that adolescence is also the period of emerging psychopathology and sensitivity to socioenvironmental contexts and stress.24,25
Previous studies2,26 have examined determinants of polysubstance use relative to non-users and primarily in the context of past 30-day use.8 While these approaches provide valuable insights, they do not fully capture the risk drivers among adolescents who engage in higher-risk use patterns. Particularly in the context of higher-risk problematic patterns of poly-product use (eg, use of multiple tobacco or cannabis products on the same day [same-day poly-product use]) or poly-drug use (use of multiple tobacco and cannabis products on the same day), understanding the multilevel factors associated with these higher-risk use patterns, compared to their substance-using counterparts who do not engage in such use patterns, is essential.
The dichotomous cutoffs (ie, yes vs. no polysubstance use) treat individuals who engage in sporadic substance use the same as those who are frequent users. This can mask important differences in risk profiles, as the factors driving occasional use (eg, social experimentation) may differ greatly from those influencing heavy, habitual use (eg, dependence, coping with stress).27 To advance current knowledge, this study examined the association of intrapersonal, psychological, social, and environmental factors with frequency of same-day tobacco and/or cannabis poly-product use, poly-drug use, and nicotine and THC vape mixing among adolescents who use tobacco or cannabis. We hypothesize that correlates will vary based on usage frequency and poly-product use patterns.
Methods
Study Sample
Data for the current study were from a school-based cohort study examining adolescent social and behavioral health issues. Eleven high schools from seven school districts in southern California participated in the study. The conduct of the study and the secondary analyses of the data were approved by the University Institutional Review Boards (IRB). Before enrollment, students provided written assent and written consent from their parents/guardians. Data were collected through in-classroom surveys administered via computers. Details on participant recruitment and the methodology of the parent study are published elsewhere.28 The analysis for this study used cross-sectional data from wave 5 (09/2022–12/2022) and the sample consisted of adolescents who reported using at least one type of tobacco/nicotine (eg, cigarette, e-cigs, heated tobacco products, smokeless tobacco, nicotine pouches, oral nicotine pouches, big/little cigars, hookah, or e-hookah) or cannabis products (eg, blunts, marijuana, edibles, vape THC, marijuana concentrates, or delta 8) within the past 6 months (n = 536).
Measurement
Outcome Variables
Same Day Poly-Tobacco/Nicotine Product Use. Adolescents were asked to indicate if they used “two or more different types of nicotine/tobacco on the same day? (e.g., smoked a cigarette and later that day vaped nicotine)” in the past 30 days.
Same Day Poly-Cannabis Product Use. Adolescents indicated if in the past 30 days they “used two or more different types of marijuana or THC on the same day? (e.g., vaped marijuana and later that same day smoked a marijuana joint or had a marijuana edible)”.
Same Day Tobacco and Cannabis Product Poly-Drug Use. Adolescents were asked if, in the past 30 days, they used “both nicotine and marijuana or THC on the same day? (e.g., vaped nicotine and later that day vaped marijuana)”.
Nicotine and THC Vape Mixing. Adolescents indicated if in the past 30 days they “vaped a solution that contained a mixture of both nicotine and THC?”.
For each of the variables, response options were “never”, “once or twice”, “some days”, “most days”, and “every day”. In line with previous work29,30 and to capture variability in categories of usage frequency and determinants, response options were coded into three categories: no same-day use (0 times), infrequent use (once or twice in the past 30 days), and frequent use (ranging from some days to most days/every day).
Exposure Variables
Intrapersonal Factors. Sociodemographic covariates included in the analysis were biological sex (male vs. female), family financial status (well off, above average, struggling, or in poverty), and academic performance (on a scale of 0 “mostly F’s” to 8 “mostly A’s”). Due to the racial/ethnic distribution of the analytic sample (66% Hispanic), ethnicity status (Hispanic vs non-Hispanic) was included as a covariate.
Past 30-Day Alcohol Use. Given the predominance of alcohol use among adolescents and studies showing that many adolescents who co-use tobacco/nicotine and cannabis use alcohol, past 30-day alcohol use (yes vs. no) was included as a covariate.8
Psychological Factors. The Revised Child Anxiety and Depression Scale was used to assess anxiety and depression, two predominant psychological factors among adolescents. Anxiety was measured with the 6-item Generalized Anxiety Disorder (GAD) subscale, while depression was evaluated using the 10-item Major Depressive Disorder (MDD) subscale. Items are rated on a 4-point Likert scale from 0 (“never”) to 3 (“always”). Participants’ sex- and grade-based standardized t-scores were computed and clinical cutoff thresholds were used to categorize participants into three levels: none (T-score ≤ 65), borderline (T-score 65–69), and clinical (T-score ≥ 70).31
Societal Factors. Two societal factors were examined: daily experiences of discrimination and concerns with societal issues (CWS). Experiences of discrimination were assessed using the 11-item Everyday Discrimination Scale,32 which assesses race/ethnicity-related discriminatory events encountered in daily life. Items are rated on a scale from 0 (“never”) to 3 (“always”), with higher scores indicating more frequent experiences of everyday discrimination (range: 0–33; Cronbach’s alpha = 0.95). To assess CWS, four questions each asked about participants’ degree of concern, worry, and stress toward issues in society. Questions asked about: (1) increasing hostility and discrimination of people because of their race, ethnicity, sexual orientation/identity, immigrant status, religion, or disability status in society; (2) shootings or violence in society; (3) police brutality or the unfair treatment of members in your community by law enforcement; and (4) mental well-being of my friends and peers. Each item was rated on a scale from 0 (“not at all”) to 4 (“extremely”), with higher scores indicating greater CWS (range: 0–16; Cronbach’s = 0.91).
Substance Use Exposure in the Environment. Secondhand exposure to tobacco/cannabis smoke or vapor (SHS) in participants’ physical environment was assessed with questions on home and public exposure. Three questions each asked participants to indicate whether they were exposed to anyone smoking/vaping cigarettes or cannabis in their presence at home or in an enclosed public space other than their home in the past week. Response options for both home and public SHS exposure were from 0 (“0 days”) to 4 (“7 days a week”). Scores were summed (range: 0–21) so that a higher score indicates greater home or public exposure to SHS.
Statistical Analysis
Descriptive statistics were computed to describe adolescents in the study. Given the small sample sizes in some outcome categories, Firth’s bias-corrected multinomial logistic regression was employed for multivariate analyses.33,34 Four separate multinomial regression models were fit for each of the three-level (no use, infrequent use, frequent use) study outcomes with no use as the reference group. To compare infrequent with frequent same-day use, another set of multinomial models was fit with infrequent use as the reference group. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) are reported. Variance Inflation Factor was used to assess multicollinearity among the independent variables, and the results indicated no multicollinearity concerns. To reduce the risk of biased estimates, random forest imputation was used to handle missing data.35 All statistical procedures were implemented in R (version 4.4.1) and R-Studio (version 2024.04.2 + 764). The package “brglm2” in R was used to conduct Firth’s bias-corrected multinomial logistic regressions in the current study.36 Statistical significance was determined at the 0.05 level.
Results
The majority of study participants were male (62.50%, n = 335) and of Hispanic ethnicity (66.23%, n = 355). As shown in Table 1, ⁓47% of participants reported past 30-day alcohol use, and 7.65% and 22.76% were classified as having clinical levels of GAD and MDD symptoms respectively. Among these adolescents who reported using tobacco/cannabis in the past 6 months, same-day poly-cannabis use was the most common use pattern (30.41%) followed by poly-drug (24.26%), poly-tobacco/nicotine (17.72%), and vape mixing (9.14%). Regarding usage frequency, the proportion of participants that reported frequent same-day poly-cannabis and poly-drug use was similar (13.81% and 13.25%, respectively) while 8.58% reported frequent same day poly-tobacco/nicotine, and 3.36% reported frequent nicotine and THC vape mixing.
Table 1.
Sample characteristics of 10th and 11th grade Southern California high school students (n = 536)
| Variable | Overall n (%)a |
|---|---|
| Intrapersonal factors | |
| Ethnicity | |
| Non-Hispanic | 181 (33.77%) |
| Hispanic | 355 (66.23%) |
| Biological sex | |
| Male | 335 (62.50%) |
| Female | 201 (37.50%) |
| Family financial status | |
| Well off | 482 (89.93%) |
| About average | 13 (2.43%) |
| Struggling or in poverty | 41 (7.65%) |
| Academic grades (M/SD)b | 5.75 (1.81) |
| Past 30-days alcohol use | |
| No | 283 (52.80%) |
| Yes | 253 (47.20%) |
| Psychological factors | |
| Clinical GADc | |
| None | 482 (89.93%) |
| Borderline | 13 (2.43%) |
| Clinical | 41 (7.65%) |
| Clinical MDDc | |
| None | 365 (68.10%) |
| Borderline | 49 (9.14%) |
| Clinical | 122 (22.76%) |
| Societal factors | |
| Concern with societal issues (M/SD)d | 8.35 (3.98) |
| Discrimination (M/SD)e | 9.34 (7.05) |
| Substance use exposure in physical environment f | |
| Secondhand home smoke/vape exposure (M/SD) | 1.50 (2.62) |
| Secondhand public smoke/vape exposure (M/SD) | 3.15 (3.20) |
| Frequency of same-day co-use patterns | |
| Poly-tobacco/nicotine product use | |
| No use | 441 (82.28%) |
| Infrequent use | 49 (9.14%) |
| Frequent use | 46 (8.58%) |
| Poly-cannabis product use | |
| No use | 373 (69.59%) |
| Infrequent use | 89 (16.60%) |
| Frequent use | 74 (13.81%) |
| Tobacco/nicotine and cannabis poly-drug co-use | |
| No use | 406 (75.75%) |
| Infrequent use | 59 (11.01%) |
| Frequent use | 71 (13.25%) |
| Nicotine and THC vape mixing | |
| No use | 481 (90.86%) |
| Infrequent use | 31 (5.78%) |
| Frequent use | 18 (3.36%) |
Notes: The study sample are 10th and 11th grade students who used any tobacco/cannabis products in past 6 months.
n (%) unless otherwise noted. M = Mean, SD = Standard Deviation.
Range: 0–8, where 0 indicates mostly F’s and 8 indicates mostly A’s.
Represents the sex- and grade-standardized T-score clinical cutoffs.
Concern with societal issues score: Range 0–16.
Everyday Discrimination Scale score: Range 0–33.
Secondhand smoke/vape home/public exposure: Range 0–21.
GAD = Generalized Anxiety Disorder, MDD = Major Depressive Disorder.
Tables 2–5 present the results of the multinomial regression models showing the correlates of the different same-day use patterns among adolescents in the study. Figure 1 additionally provides a visual summary of the correlates of the different polysubstance use patterns. All models were adjusted for sex, grades, family financial status, and ethnicity.
Table 2.
Results of multinomial logistic regression analysis of factors associated with past 30-day same-day poly-tobacco/nicotine product use frequency (no same-day poly-tobacco/nicotine use, infrequent use, frequent use) among participants
| Variable | Infrequent vs. No same-day poly-tobacco/nicotine use | Frequent vs. No same-day poly-tobacco/nicotine use | Frequent vs. Infrequent same-day poly-tobacco/nicotine use |
|---|---|---|---|
| aOR (95% CI)a | aOR (95% CI) | aOR (95% CI) | |
| Intrapersonal factors | |||
| Ethnicity | |||
| Non-Hispanic | Ref | ||
| Hispanic | 1.91 (0.90, 4.07) | 1.07 (0.50, 2.29) | 0.56 (0.21, 1.49) |
| Biological sex | |||
| Male | Ref | ||
| Female | 0.53 (0.27, 1.07) | 1.23 (0.58, 2.63) | 2.31 (0.90, 5.94) |
| Family financial status | |||
| Well off | Ref | ||
| About average | 1.43 (0.62, 3.30) | 1.42 (0.54, 3.74) | 0.99 (0.30, 3.24) |
| Struggling or in poverty | 1.5 (0.60, 3.76) | 1.14 (0.40, 3.26) | 0.76 (0.21, 2.75) |
| Academic gradesb | 0.94 (0.79, 1.12) | 0.84 (0.70, 1.01) | 0.89 (0.71, 1.11) |
| Past 30-day alcohol use | |||
| No | Ref | ||
| Yes | 2.94 (1.55, 5.60) ** | 7.95 (3.22, 19.63) ** | 2.70 (0.93, 7.81) |
| Psychological factors | |||
| Clinical GADc | |||
| None | Ref | ||
| Borderline | 1.16 (0.23, 5.97) | 0.55 (0.08, 3.95) | 0.48 (0.05, 4.23) |
| Clinical | 0.28 (0.05, 1.70) | 0.39 (0.10, 1.58) | 1.38 (0.16, 11.60) |
| Clinical MDDc | |||
| None | Ref | ||
| Borderline | 0.47 (0.12, 1.83) | 1.11 (0.10, 1.58) | 2.35 (0.39, 14.07) |
| Clinical | 0.89 (0.39, 2.02) | 1.29 (0.53, 3.15) | 1.46 (0.49, 4.38) |
| Societal factors | |||
| Concern with societal issuesd | 0.93 (0.85, 1.02) | 1.10 (0.99, 1.22) | 1.18 (1.03, 1.34) * |
| Discriminatione | 1.03 (0.97, 1.09) | 1.01 (0.95, 1.07) | 0.98 (0.91, 1.06) |
| Secondhand smoke/vape exposure in physical environment f | |||
| Secondhand home exposure | 1.10 (0.97, 1.26) | 1.15 (1.01, 1.30) * | 1.04 (0.89, 1.22) |
| Secondhand public exposure | 1.05 (0.94, 1.17) | 1.23 (1.09, 1.38) ** | 1.17 (1.01, 1.35)* |
Notes: Boldface indicates statistical significance (***p < .001, **p < .01, *p < .05).
aOR = adjusted Odds Ratio; 95% CI = 95% Confidence Interval.
Range: 0–8, where 0 indicates mostly F’s and 8 indicates mostly A’s.
Represents the sex- and grade-standardized T-score clinical cutoffs.
Concern with societal issues score: Range 0–16.
Everyday Discrimination Scale score: Range 0–33.
Secondhand smoke/vape home/public exposure: Range 0–21.
GAD = Generalized Anxiety Disorder, MDD = Major Depressive Disorder.
Table 5.
Results of multinomial logistic regression analysis of factors associated with past 30-day same-day nicotine and THC vape mixing frequency (no same-day vape mixing, infrequent use, frequent use) among participants
| Variable | Infrequent vs. No same day vape mixing | Frequent vs. No same day vape mixing | Infrequent vs. Frequent same day vape mixing |
|---|---|---|---|
| aOR (95% CI)a | aOR (95% CI) | aOR (95% CI) | |
| Intrapersonal factors | |||
| Ethnicity | |||
| Non-Hispanic | Ref | ||
| Hispanic | 2.34 (0.93, 5.91) | 2.52 (0.76, 8.31) | 1.08 (0.25, 4.63) |
| Biological sex | |||
| Male | Ref | ||
| Female | 0.40 (0.17, 0.96) * | 1.15 (0.41, 3.22) | 2.87 (0.79, 10.45) |
| Family financial status | |||
| Well off | Ref | ||
| About average | 0.98 (0.38, 2.50) | 0.61 (0.19, 1.97) | 0.63 (0.15, 2.62) |
| Struggling or in poverty | 1.25 (0.45, 3.48) | 0.32 (0.08, 1.35) | 0.26 (0.05, 1.38) |
| Academic gradesb | 0.96 (0.79, 1.17) | 0.93 (0.72, 1.20) | 0.97 (0.71, 1.31) |
| Past 30-days alcohol use | |||
| No | Ref | ||
| Yes | 1.36 (0.66, 2.81) | 2.99 (0.95, 9.40) | 2.20 (0.59, 8.21) |
| Psychological factors | |||
| Clinical GADc | |||
| None | Ref | ||
| Borderline | 1.49 (0.20, 11.10) | 2.29 (0.34, 15.54) | 1.54 (0.13, 18.80) |
| Clinical | 1.10 (0.25, 4.91) | 0.50 (0.04, 5.61) | 0.45 (0.03, 7.10) |
| Clinical MDDc | |||
| None | Ref | ||
| Borderline | 0.84 (0.22, 3.20) | 1.46 (0.25, 8.41) | 1.73 (0.21, 14.60) |
| Clinical | 0.98 (0.37, 2.59) | 0.57 (0.13, 2.57) | 0.59 (0.10, 3.28) |
| Societal factors | |||
| Concern with societal issuesd | 0.93 (0.84, 1.03) | 0.88 (0.75, 1.04) | 0.95 (0.79, 1.14) |
| Discriminatione | 0.98 (0.92, 1.05) | 1.11 (1.02, 1.20) * | 1.13 (1.02, 1.25) * |
| Substance use exposure in physical environmentf | |||
| Secondhand home smoke/vape exposure | 1.09 (0.94, 1.27) | 1.24 (1.05, 1.46) ** | 1.14 (0.93, 1.40) |
| Secondhand public smoke/vape exposure | 1.07 (0.94, 1.21) | 1.11 (0.94, 1.32) | 1.04 (0.85, 1.27) |
Notes: Boldface indicates statistical significance (***p < .001, **p < .01, *p < .05).
aOR = adjusted Odds Ratio; 95% CI = 95% Confidence Interval.
Range: 0–8, where 0 indicates mostly F’s and 8 indicates mostly A’s.
Represents the sex- and grade-standardized T-score clinical cutoffs.
Concern with societal issues score: Range 0–16.
Everyday Discrimination Scale score: Range 0–33.
Secondhand home/public exposure to any nicotine or cannabis products: Range 0–21.
GAD = Generalized Anxiety Disorder, MDD = Major Depressive Disorder.
Figure 1.
Factors significantly associated with past 30-day same-day poly-tobacco/nicotine product use frequency, poly-cannabis product use frequency, poly-drug co-use frequency, and nicotine and THC vape mixing frequency (relative to no same-day use) among study participants.
Table 3.
Results of multinomial logistic regression analysis of factors associated with past 30-day same-day poly-cannabis product use frequency (no same-day poly-cannabis use, infrequent use, frequent use) among participants
| Variable | Infrequent vs. No same-day poly-cannabis use | Frequent vs. No same-day poly-cannabis use | Frequent vs. Infrequent same-day poly-cannabis use |
|---|---|---|---|
| aOR (95% CI)a | aOR (95% CI) | aOR (95% CI) | |
| Intrapersonal factors | |||
| Ethnicity | |||
| Non-Hispanic | Ref | ||
| Hispanic | 1.58 (0.90, 2.77) | 1.71 (0.89, 3.30) | 1.08 (0.51, 2.31) |
| Biological sex | |||
| Male | Ref | ||
| Female | 1.08 (0.64, 1.82) | 1.31 (0.70, 2.46) | 1.21 (0.60, 2.44) |
| Family financial status | |||
| Well off | Ref | ||
| About average | 0.56 (0.31, 1.01) | 0.93 (0.42, 2.05) | 1.66 (0.70, 3.93) |
| Struggling or in poverty | 0.61 (0.30, 1.21) | 1.22 (0.52, 2.83) | 2.01 (0.78, 5.12) |
| Academic gradesb | 0.89 (0.78, 1.02) | 0.87 (0.74, 1.01) | 0.97 (0.82, 1.16) |
| Past 30-days alcohol use | |||
| No | Ref | ||
| Yes | 1.88 (1.14, 3.09) * | 4.26 (2.26, 8.01) *** | 2.27 (1.11, 4.66) * |
| Psychological factors | |||
| Clinical GADc | |||
| None | Ref | ||
| Borderline | 0.42 (0.06, 2.88) | 0.72 (0.15, 3.58) | 1.72 (0.20, 14.46) |
| Clinical | 0.25 (0.06, 1.04) | 0.38 (0.11, 1.26) | 1.51 (0.28, 8.18) |
| Clinical MDDc | |||
| None | Ref | ||
| Borderline | 0.64 (0.24, 1.69) | 1.23 (0.44, 3.41) | 1.93 (0.54, 6.86) |
| Clinical | 0.83 (0.42, 1.66) | 0.94 (0.44, 2.02) | 1.13 (0.47, 2.72) |
| Societal factors | |||
| Concern with societal issuesd | 0.92 (0.85, 0.98) * | 1.02 (0.94, 1.12) | 1.12 (1.01, 1.24) * |
| Discriminatione | 1.05 (1.001, 1.093) * | 1.05 (1.00, 1.10) | 1.00 (0.95, 1.06) |
| Secondhand smoke/vape exposure in physical environment f | |||
| Secondhand home exposure | 1.06 (0.94, 1.19) | 1.18 (1.05, 1.32) ** | 1.12 (0.98, 1.27) |
| Secondhand public exposure | 1.13 (1.03, 1.24) * | 1.20 (1.09, 1.33) *** | 1.07 (0.95, 1.20) |
Notes: Boldface indicates statistical significance (***p < .001, **p < .01, *p < .05).
aOR = adjusted Odds Ratio; 95% CI = 95% Confidence Interval.
Range: 0–8, where 0 indicates mostly F’s and 8 indicates mostly A’s.
Represents the sex- and grade-standardized T-score clinical cutoffs.
Concern with societal issues score: Range 0–16.
Everyday Discrimination Scale score: Range 0–33.
Secondhand smoke/vape home/public exposure: Range 0–21.
GAD = Generalized Anxiety Disorder, MDD = Major Depressive Disorder.
Table 4.
Results of multinomial logistic regression analysis of factors associated with past 30-day same-day poly-drug co-use frequency (no same-day poly-drug co-use, infrequent use, frequent use) among participants
| Variable | Infrequent vs. No same day poly-drug use | Frequent vs. No same day poly-drug use | Infrequent vs. Frequent same day poly-drug use |
|---|---|---|---|
| aOR (95% CI)a | aOR (95% CI) | aOR (95% CI) | |
| Intrapersonal factors | |||
| Ethnicity | |||
| Non-Hispanic | Ref | ||
| Hispanic | 1.05 (0.55, 1.98) | 1.36 (0.68, 2.71) | 1.29 (0.57, 2.92) |
| Biological sex | |||
| Male | Ref | ||
| Female | 0.57 (0.30, 1.09) | 0.78 (0.39, 1.54) | 1.35 (0.59, 3.11) |
| Family financial status | |||
| Well off | Ref | ||
| About average | 0.83 (0.40, 1.69) | 1.15 (0.50, 2.60) | 1.39 (0.53, 3.63) |
| Struggling or in poverty | 1.16 (0.52, 2.55) | 1.63 (0.67, 3.96) | 1.41 (0.50, 3.95) |
| Academic gradesb | 1.02 (0.86, 1.20) | 1.03 (0.87, 1.23) | 1.02 (0.83, 1.25) |
| Past 30-days alcohol use | |||
| No | Ref | ||
| Yes | 3.93 (2.15, 7.18) *** | 8.31(3.93, 17.56) ** | 2.11 (0.87, 5.14) |
| Psychological factors | |||
| Clinical GADc | |||
| None | Ref | ||
| Borderline | 1.09 (0.21, 5.57) | 0.87 (0.17, 4.53) | 0.80 (0.12, 5.12) |
| Clinical | 0.29 (0.07, 1.22) | 0.48 (0.14, 1.63) | 1.68 (0.32, 8.95) |
| Clinical MDDc | |||
| None | Ref | ||
| Borderline | 0.56 (0.17, 1.81) | 0.71 (0.20, 2.57) | 1.28 (0.26, 6.34) |
| Clinical | 1.54 (0.74, 3.19) | 1.69 (0.78, 3.70) | 1.10 (0.45, 2.71) |
| Societal factors | |||
| Concern with societal issuesd | 0.98 (0.90, 1.06) | 0.96 (0.88, 1.06) | 0.99 (0.89, 1.10) |
| Discriminatione | 1.00 (0.95, 1.06) | 1.02 (0.97, 1.08) | 1.02 (0.96, 1.09) |
| Substance use exposure in physical environmentf | |||
| Secondhand home smoke/vape exposure | 1.08 (0.94, 1.24) | 1.26 (1.12, 1.42) ** | 1.17 (1.01, 1.35) * |
| Secondhand public smoke/vape exposure | 1.10 (0.99, 1.22) | 1.18 (1.06, 1.31) ** | 1.07 (0.94, 1.22) |
Notes: Boldface indicates statistical significance (***p < .001, **p < .01, *p < .05).
aOR = adjusted Odds Ratio; 95% CI = 95% Confidence Interval.
Range: 0–8, where 0 indicates mostly F’s and 8 indicates mostly A’s.
Represents the sex- and grade-standardized T-score clinical cutoffs.
Concern with societal issues score: Range 0–16.
Everyday Discrimination Scale score: Range 0–33.
Secondhand smoke/vape home/public exposure: Range 0–21.
GAD = Generalized Anxiety Disorder, MDD = Major Depressive Disorder.
Same Day Poly-Tobacco/Nicotine Use. Alcohol use was associated with higher odds of both infrequent (aOR = 2.94, 95% CI: 1.55, 5.60) and frequent (aOR = 7.95, 95% CI: 3.22, 19.63) use relative to no same day poly-tobacco/nicotine use. Exposure to secondhand smoke/vapor at home (aOR = 1.15, 95% CI: 1.01, 1.30) and in public (aOR = 1.23, 95% CI: 1.09, 1.38) was associated with higher odds of frequent same day poly-tobacco/nicotine use relative to no same day use.
Same Day Poly-Cannabis Use. Adolescents who used alcohol were at higher odds of infrequent (aOR = 1.88, 95% CI: 1.14, 3.09) and frequent (aOR = 4.26, 95% CI: 2.26, 8.01) same day use relative to no same day use. Higher societal concern was associated with lower odds of infrequent same day use (aOR = 0.92, 95% CI: 0.85, 0.98) while higher discrimination scores were associated with higher odds of infrequent same day use (aOR = 1.05, 95% CI: 1.001, 1.093) relative to no same day use. Home exposure to SHS was associated with higher odds of frequent same day use (aOR = 1.18, 95% CI 1.05 1.32) while public exposure to SHS was associated with higher odds of both infrequent (aOR = 1.13, 95% CI: 1.03, 1.24) and frequent (aOR = 1.20, 95% CI: 1.09, 1.33) same day use relative to no same day use.
Same Day Poly-Drug Use. Adolescents who used alcohol had higher odds of both infrequent (aOR = 3.93, 95% CI: 2.15, 7.18) and frequent (aOR = 8.31, 95% CI: 3.92, 17.56) same day poly-drug use relative to no same day poly-drug use. Home and public exposure to SHS was associated with higher odds of frequent same day TCU (aOR = 1.26, 95% CI: 1.12, 1.42 and aOR = 1.18, 95% CI: 1.06, 1.31) relative to no same day poly-drug use.
Same Day Nicotine and THC Vape Mixing. Relative to females, adolescent males had lower odds of vape mixing (aOR = 0.40, 95% CI: 0.17, 0.96). Higher discrimination and SHS exposure in the home were associated with higher odds of frequent vape mixing (aOR = 1.11, 95% CI: 1.02, 1.20 and aOR = 1.24, 95% CI: 1.05, 1.46) relative to no same day vape mixing.
Comparing Correlates of Same Day Frequent Use Relative to Infrequent Use. Adolescents with higher societal concern (aOR = 1.18, 95% CI: 1.03, 1.34) and public exposure to SHS (aOR = 1.17, 95% CI: 1.01, 1.35) had higher odds of frequent same day poly-tobacco/nicotine use (vs. infrequent poly-tobacco/nicotine use). For same day poly-cannabis use, alcohol use (aOR = 2.27, 95% CI: 1.11, 4.66) and societal concern (aOR = 1.12, 95% CI: 1.01, 1.24) were associated with higher odds of frequent (vs. infrequent) use. However, only home exposure to SHS was associated with higher odds of frequent (vs. infrequent) same day poly-cannabis use (aOR = 1.17, 95% CI: 1.01, 1.35), and only higher discrimination experiences were associated with frequent (vs. infrequent) nicotine and THC vape mixing (aOR = 1.13, 95% CI: 1.02, 1.25).
Discussion
This study employed an ecological perspective, which emphasizes that individual behaviors are shaped by multiple interacting levels of influence,22 to identify intrapersonal, psychological, societal, and environmental determinants associated with same day poly-tobacco/nicotine, poly-cannabis, poly-drug, and nicotine/THC vape mixing among adolescents who use tobacco/cannabis. Previous studies of polysubstance use37 investigate dichotomous (yes vs. no) past 30-day variables for modeling polysubstance use while examining risks and determinants relative to adolescents who report no substance use. This study expands previous research by identifying factors associated with same-day tobacco/nicotine and cannabis poly-use patterns, as well as usage frequencies (no same day, infrequent, frequent use), among adolescents who use these substances. As hypothesized, correlates of same day use varied based on usage frequency and poly-product use pattern, with alcohol use and environmental context being the most prominent correlates. Specifically, alcohol use and public exposure to SHS were implicated in frequent same day poly-tobacco/nicotine, poly-cannabis, and poly-drug use among adolescents who use tobacco/cannabis. While psychological health (clinical indication of anxiety and depression) was not a significant predictor of these poly-substance use patterns, societal and physical environmental factors were relevant risk correlates that distinguished risk of frequent use relative to infrequent use/co-use and vape mixing.
At the intrapersonal level, current alcohol use was associated with reports of both infrequent and frequent poly-tobacco/nicotine, poly-cannabis, and poly-drug co-use but not nicotine and THC vape mixing. Previous studies have demonstrated an association between alcohol use and tobacco and cannabis co-use,38,39 but this study expands on this work by highlighting the strong relationship between alcohol use and higher-risk tobacco and/or cannabis use patterns (ie, high-frequency same-day poly-product and poly-drug use), especially among adolescents who use tobacco and/or cannabis. Previous work has demonstrated that shared social environments in which substances are available and accessible, the common risk liability of substances, and the facilitating role of using licit substances like alcohol contribute to the likelihood of using multiple substances simultaneously.8,40 Given that this study did not assess alcohol use at the event level, future work is needed to understand the mechanisms and context underlying the specific role of alcohol in higher-risk polysubstance use among diverse adolescents who use tobacco/nicotine and/or cannabis.
Anxiety and depression often emerge during adolescence and have been linked to the use of and risk for polysubstances.4,41,42 However, this study found no association between these psychological health symptoms and all study outcomes. This finding is similar to Williams et al.’s (2022) study of Canadian adolescents where they found that anxiety or depression did not predict polysubstance use, rather, adolescents who reported polysubstance use had worsened anxiety and depression symptoms over time.43 Although this study’s null finding could be a result of the sample size, location, and demographic (ie, predominantly Hispanic substance-using adolescents in Southern California), it is also possible that the lack of association is indicative of a limited impact of anxiety and depression on higher-risk substance use patterns (ie, same day use) among substance-using adolescents. This finding highlights the need for future work that uses advanced methodologies (such as latent variable mixture modeling) to establish group-based trajectories that can assess whether anxiety and depression play differential roles in initiation versus problematic substance use patterns (eg, escalation, high-risk) among substance-using adolescents from diverse racial/ethnic groups.8,44
In this study of adolescents who use tobacco and/or cannabis, societal factors (such as concerns about societal issues and experiences of discrimination) had mixed effects on the various polysubstance use patterns and frequency. Specifically, discrimination was linked to a higher likelihood of infrequent poly-cannabis use and frequent nicotine and THC vape mixing, while concern about societal issues (including hostility, police brutality, school shootings, and peer mental health) was associated with lower odds of infrequent same day poly-cannabis use compared to no same day use. Notably, discrimination was a key factor differentiating frequent nicotine and THC vape mixing, whereas concerns about societal issues distinguished frequent same day poly-tobacco/nicotine use and poly-cannabis use from infrequent same day use patterns. Racial discrimination has been linked to polysubstance use among adolescents, especially for racial/ethnic minorities,45 and recent studies have emphasized the importance of societal factors in substance use development and the need for more evidence on the role of race/ethnicity-related societal issues and contexts on polysubstance use patterns among diverse adolescents who use substances.8 This study’s finding that factors such as concern with issues in society and racial discrimination were related to frequent use (relative to infrequent use) of various polysubstance use patterns further highlights the promotive role of social systems in polysubstance use.45 However, the contrasting evidence for infrequent poly-cannabis use could be indicative of the need for future studies on the impact of the intersection of societal issues, race/ethnicity, and context (eg, geography) with specific poly-product use patterns among adolescents.
Previous studies have shown that secondhand tobacco and cannabis smoke exposures have similar toxicants and carcinogens,46 are preventable causes of mortality and morbidity,47 and that younger, socioeconomically disadvantaged, racial/ethnic minority individuals are most exposed.47,48 These previous works together with this study’s finding that socioenvironmental factors differentiated frequent and infrequent usage provide critical evidence needed to support the need for multilevel and comprehensive substance use prevention policies. While SHS from tobacco/cannabis has a demonstrated impact on respiratory function,46,47 this study’s findings suggest that additional exposure to secondhand tobacco/cannabis vapor in homes and public spaces could have an impact on social and behavioral norms surrounding substance/polysubstance use, especially among adolescents who already have to contend with multiple levels of factors influencing their susceptibility to substances.49,50 Additionally, exposure to SHS may reflect an environment (physical and social) that increases susceptibility and biological sensitivity to nicotine and/or cannabis and is often accompanied by psychosocial factors that collectively elevate the risk of poly-product use.51,52 Particularly for addressing disparities in substance use and use disorders, this finding supports the need to expand current indoor air or smoke-free policies to include vape products to prevent renormalization of tobacco product use and involuntary exposure to aerosolized emissions from electronic delivery systems.53
The results should be interpreted considering several limitations. First, as this is a cross-sectional exploratory study, we can only identify associations and cannot establish causal relationships. Second, while the study employed measures validated among adolescents, data are self-reported and are subject to bias in reports and estimations. Additionally, study participants, though ethnically diverse, are not nationally representative which could limit the generalizability of the findings. Participants are also from California, a state where cannabis is legal for medicinal and recreational use for adults (≥21 years), and which has a stricter regulation on SHS exposure and tobacco product sales which could have impacts on the study’s exposures and outcomes.
In summary, this study contributes uniquely to the discussion on polysubstance use, specifically regarding tobacco/nicotine-cannabis co-use and poly-product use patterns and frequencies. It employs an ecological lens to differentiate among intrapersonal (eg, alcohol use, anxiety, and depression), societal (eg, discrimination, societal concerns), and environmental (eg, secondhand smoke exposure) correlates of same-day poly-tobacco/nicotine, poly-cannabis, poly-drug use, and nicotine/THC vape mixing among adolescents who use tobacco and/or cannabis. Going beyond previous research that examines polysubstance use as a dichotomy (yes vs. no), this study distinguishes between infrequent and frequent same-day use patterns and their correlates, revealing that higher-frequency use is consistently associated with alcohol use and socio-environmental exposures, particularly public exposure to secondhand smoke or vapor. While the psychological symptoms examined (anxiety and depression) were not associated with any use patterns in this sample—aligning with emerging findings that challenge the presumed universality of psychological risk factors—societal concerns and experiences of discrimination showed varied associations across use patterns. For instance, discrimination was linked to increased odds of frequent nicotine/THC vape mixing, while concern over societal issues was associated with lower odds of infrequent poly-cannabis use and higher odds of frequent poly-tobacco and poly-cannabis use. These findings provide nuanced insights into multilevel influences, particularly how environmental and societal factors distinguish higher-risk substance use patterns among adolescents already using tobacco and/or cannabis. Consequently, this highlights the need for future longitudinal research to better understand the commonalities and differences in the drivers of various product use patterns among racial and ethnic groups of adolescents who use tobacco and cannabis products.8 This knowledge is crucial for developing tailored, multi-tiered interventions to address high-risk polysubstance use among adolescents.54
Contributor Information
Wura Jacobs, Department of Applied Health Science, School of Public Health, Indiana University Bloomington, 1025 E. Seventh Street, Suite 116, Bloomington, IN 47405.
Weisiyu A Qin, Department of Applied Health Science, School of Public Health, Indiana University Bloomington, 1025 E. Seventh Street, Suite 116, Bloomington, IN 47405.
Nikki S Jafarzadeh, Institute for Addiction Science, Keck School of Medicine, University of Southern California.
Jessica Barrington-Trimis, Institute for Addiction Science, Keck School of Medicine, University of Southern California.
Adam M Leventhal, Institute for Addiction Science, Keck School of Medicine, University of Southern California.
Author Contributions
Wura Jacobs (Conceptualization [lead], Investigation [lead], Methodology [lead], Project administration [lead], Supervision [lead], Writing—original draft [lead], Writing—review & editing [lead]), Weisiyu Abraham Qin (Conceptualization [supporting], Data curation [equal], Formal analysis [lead], Methodology [equal], Writing—original draft [equal], Writing—review & editing [equal]), Nikki Sayeh Jafarzadeh (Validation [equal], Writing—review & editing [equal]), Jessica Barrington-Trimis (Data curation [equal], Funding acquisition [equal]), and Adam Leventhal (Data curation [equal], Funding acquisition [equal], Validation [equal], Writing—review & editing [equal])
Funding
This work was supported by grants K24DA048160 [PI: AML], R01CA229617 [MPI: JBT & AML], and R01CA229617-03S1 [MPI: JBT & AML, Co-I: WJ] from National Institute on Drug Abuse and the National Cancer Institute. The funding agency had no role in the research; the views expressed in this paper do not represent those of the funding agency.
Declaration of Interests
None.
Data Availability
Data are not publicly available but can be requested from the principal investigators of the study (AML and JBT).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are not publicly available but can be requested from the principal investigators of the study (AML and JBT).