Abstract
Background:
Tobacco and cannabis co-use prevalence is rising, with older adults disproportionately impacted.
Objective:
Assess tobacco and cannabis co-use by health and sociodemographic characteristics among adults 65+ years.
Methods:
Using National Survey on Drug Use and Health nationally representative data (2021-2023), we estimated past-month tobacco and cannabis co-use prevalence among adults 65+ years (N=15,672). Multinomial logistic regressions examined associations between health and sociodemographic characteristics with past-month co-use, tobacco-only use, and cannabis-only use (vs. former use).
Results:
One in six reported past-month use of either cannabis or tobacco (1.7% co-used). More chronic disease diagnoses was associated with lower co-use (e.g., one vs. none: adjusted relative risk ratio [aRRR]=0.47). Co-use was higher among people with worse self-rated health (e.g., fair/poor vs. excellent/very good: aRRR=2.73) and past-year mental illness (aRRR=2.07).
Conclusions:
Clinicians working with older adults should account for cannabis co-use in tobacco cessation and disseminate evidence-based cannabis information.
Keywords: tobacco use, cannabis, marijuana smoking, tobacco use disorder, behavior, addictive
Introduction
The prevalence of past-month tobacco and cannabis co-use (i.e., use of both substances in the same period, either separately or simultaneously such as in “blunts”) has increased for most sociodemographic groups in the United States (U.S.) (Rubenstein et al., 2024). Between 2002 and 2019, co-use among the overall U.S. population increased significantly (i.e., 4.4% to 6.2%) (Rubenstein et al., 2024). The rising prevalence of co-use has occurred concurrently with the expansion of state recreational and medical cannabis laws in the U.S. As of 2026, 24 states and Washington, DC have legalized adult recreational cannabis use and 41 states have medical cannabis programs (National Conference of State Legislatures, 2026). Compared to tobacco-only use, co-use of tobacco and cannabis is associated with increased toxicant exposure (Meier et al., 2016), poorer self-reported mental health (Fahey et al., 2025b; Hindocha et al., 2020; Peters et al., 2012), greater nicotine dependence (McClure et al., 2020; Wang et al., 2016) and increased difficulty quitting tobacco (Weinberger et al., 2018). Individuals co-using both products also report poorer physical health compared to those using either product alone (Fahey et al., 2025b; Tsai et al., 2017). Tobacco and cannabis co-use is an increasing public health concern considering potential additive health risks.
Tobacco and cannabis co-use is an especially relevant issue for adults ages 65 years and older. This age group is more likely to experience the negative health consequences of tobacco use in later life, and tobacco use exacerbates existing chronic health conditions that are more likely to occur in older age (U.S. Department of Health & Human Services, 2014). Despite drastic prevalence declines in younger ages, cigarette use among those 65+ years has remained stagnant for 15 years (Kleykamp & Kulak, 2023; McAfee et al., 2021). Further, cannabis use has unique potential risks as an individual ages. For example, cannabis can decrease the efficacy of prescription medications (Antoniou et al., 2020) exacerbate cardiovascular and pulmonary diseases (Minerbi et al., 2019), and increase risk of falls (Minerbi et al., 2019). Medical motivations for cannabis use (e.g., pain, insomnia) are the most common reasons for use among this age group (Kaufmann et al., 2022; Reynolds et al., 2018; Thayer et al., 2026; Yang et al., 2022), even though the U.S. Federal Drug Administration (FDA) has only approved cannabinoid-based medications for a small number of specific indications including HIV/AIDS-induced anorexia, and chemotherapy-induced nausea and vomiting (Hsu et al., 2026). While emerging observational evidence suggests potential benefits for chronic pain and insomnia symptoms, current evidence remains insufficient to support the use of cannabis or cannabinoids for most medical conditions (Hsu et al., 2026; Wang et al., 2023). Importantly, this literature is limited given methodological challenges, such as a lack of well-controlled experimental studies, and the vast heterogeneity of cannabis products (tetrahydrocannabinol [THC]-dominant versus cannabidiol [CBD]) and routes of administration (e.g., smoking, ingestion), as well as the underrepresentation of adults 65+ years (Hsu et al., 2026; Wang et al., 2023). In sum, there are unique considerations for tobacco and cannabis co-use for adults 65+ years, particularly for those with co-occurring chronic disease.
Given the rising prevalence of cannabis use among adults 65+ years (Han et al., 2019), updated reports on co-use prevalence in this age group are needed. Using the latest nationally representative data, this study aimed to assess the prevalence of tobacco and cannabis co-use among U.S. adults 65+ years and characterize the population of people who continue to use either or both products into older adulthood, focusing on health-related factors. The primary research questions were (1) What is the prevalence of past-month tobacco-only, cannabis-only, and co-use among adults 65+ years? (2) How do use patterns vary by chronic disease and other health-related outcomes and (3) What sociodemographic characteristics are associated with each pattern of use? We hypothesized that tobacco and cannabis co-use would be associated with greater chronic disease burden and that the population co-using products would systematically differ from those reporting former use. An updated understanding of the co-use landscape among adults 65+ years can inform policy development among this Medicare-eligible population (e.g., targeted screening) as well as clinical practice.
Materials & Methods
The National Survey on Drug Use and Health (NSDUH) is an annual nationally representative cross-sectional survey that provides publicly available data on U.S. noninstitutionalized population aged 12 or older (Substance Abuse and Mental Health Services Administration [SAMHSA], 2024). Participants were selected through multistage probability sampling and weighted interview response rate for 2021-2023 ranged from 46.24% to 47.43% (SAMHSA, 2022; SAMHSA, 2023; SAMHSA 2024). The NSDUH used a multi-modal data collection approach in years 2021, 2022, and 2023. Respondents were given the choice of completing screenings or questionnaires via in-person interview or via the internet. Web-based questionnaires were self-administered, and in-person interviews were facilitated by audio computer-assisted self-interviewing. Using data from 2021-2023, our study included older adults ages 65+ years (i.e., N=15,689 in 2021-2023). Older adulthood was defined as 65+ years based on the World Health Organization definition and the age at which individuals qualify for Medicare (World Health Organization, 2011). After excluding n=17 participants missing responses on health and sociodemographic characteristics, our final analytic sample was N=15,672 people ages 65+ years. This analysis of de-identified public data was exempt from institutional review board review.
Measures
Tobacco and cannabis co-use.
Respondents were prompted, “During the past 30 days, have you smoked part or all of a cigarette?” Tobacco also included past 30-day report of roll-your-own tobacco cigarettes, cigars, pipes, smokeless tobacco, and nicotine vaping. For cannabis, respondents were prompted about their use of marijuana and cannabis products (i.e., pot, weed, hashish, concentrates) via various modalities (smoking [such as in joints, pipes, bongs, blunts, hookahs], vaping [using vape pens, dab pens, tabletop vaporizers, or portable vaporizers], dabbing, eating or drinking, or applying as a lotion). Blunt use was assessed by, “Have you ever smoked part or all of a cigar with marijuana in it?” A five-level categorical variable for past-month use was constructed from these measures: both tobacco/cannabis, tobacco-only, cannabis-only, lifetime use of either/both (no past-month use), never use of tobacco/cannabis. Past-month blunt use was coded as both tobacco and cannabis use.
Chronic disease status.
Respondents were prompted, “Indicate all the conditions that a doctor or other healthcare professional has ever told you that you had.” We constructed binary indicators for each disease (i.e., diabetes, chronic bronchitis or chronic obstructive pulmonary disease [COPD], cirrhosis, hepatitis B or C, kidney disease, asthma, high blood pressure, heart condition, or cancer): yes vs. no, don’t know, or missing. We created a variable with the total number of known lifetime chronic diseases reported (i.e., count of “yes”). Only past-year information was available for heart condition (yes, no) and cancer. We categorized number of lifetime chronic diseases (i.e., 0, 1, 2, or 3+).
Other health variables.
Participants also reported if any or all of their past-year cannabis use was recommended by their doctor. Self-rated heath distinguished excellent/very good, good, and fair/poor health status. Any past-year mental illness was obtained from a well-documented NSDUH indicator based on several measures including the predicted probability of serious mental illness and the presence of past-year major depressive episode and/or suicidality (Center for Behavioral Health Statistics & Quality, 2024).
Sociodemographic characteristics.
We included sociodemographic characteristics that have been previously shown to be associated with tobacco and cannabis use or co-use (Cornelius et al., 2023; Han et al., 2020; Rubenstein et al., 2024). Self-reported characteristics included race and ethnicity (Black, Hispanic, other, White), binary sex, income (<$20,000, $20,000-$49,999, $50,000-$74,999, $75,000+), education (high school graduate/equivalent, less than high school, some college/associate’s degree, college graduate) employment (full-time, part-time, unemployed, other), veteran status, and lifetime arrest and booking (any vs. none).
Data Analysis
Data were pooled from 2021 to 2023 NSDUH surveys given consistent methodology across years; we applied complex survey weights divided by three survey years to derive nationally representative estimates that accounted for sampling and survey non-response. We first described weighted sociodemographic and health-related variables and estimated prevalences of tobacco and cannabis co-use categories. Second, we fit survey-weighted multinomial logistic regression models to examine the association between chronic disease and characteristics with our past-month co-use outcome, using former lifetime use of either/both but not past-month as the reference category, and distinguishing tobacco-only and cannabis-only. We chose not to combine never use and former use into one reference category given that these are two distinct populations, and results provide more meaningful conclusions by characterizing the population of older adults who have continued to use (rather than stop using) these products. The adjusted relative risk ratios (aRRR) and 95% confidence intervals (CI) controlled for the survey-year indicators and the clinical and sociodemographic characteristics listed above.
Results
Weighted prevalences of clinical and sociodemographic characteristics in the full sample and by chronic disease status are presented in Table 1. Overall, 37.4% of adults 65 + reported one lifetime chronic disease, 19.3% reported two, 15.2% reported 3+, and 28.1% reported none. Over a quarter (26.4%) had ever had a heart condition (13.5% in the past year) and 16.7% had ever been diagnosed with cancer (3.8% past year). Regarding other chronic disease, the most common diagnoses included high blood pressure (38.8%), diabetes (22.3%) and bronchitis/chronic obstructive pulmonary disease (COPD) (8.5%). Among our entire sample, 1.7% reported a doctor recommended any of their cannabis use in the past year (1.2% reported all their past-year cannabis use was recommended). Among the 8.3% reporting past-year cannabis use, 20.2% reported that any of their past-year use was recommended by a doctor (14.1% reported all was). Among those with any or all doctor-recommended cannabis use, 90.1%-92.7% lived in a state with a medical cannabis law passed time of interview.
Table 1.
Clinical and Sociodemographic Characteristics by Lifetime Chronic Disease Diagnoses Among Respondents 65+ Years in 2021-2023 (N = 15,672)
| Full Sample | No Diagnoses | 1 Diagnosis | 2 Diagnoses | 3+ Diagnoses | |
|---|---|---|---|---|---|
| N (Weighted Row %) | |||||
| Full Sample | 4359 (28.13) | 5551 (37.42) | 3212 (19.29) | 2550 (15.17) | |
| Chronic Conditions | |||||
| Heart Condition | |||||
| Ever heart condition | 4218 (26.38) | 0 (0.00) | 1079 (20.49) | 1341 (41.75) | 1798 (70.26) |
| Past year heart condition | 2219 (13.49) | 0 (0.00) | 527 (9.59) | 713 (22.51) | 979 (36.69) |
| Cancer | |||||
| Ever cancer | 2936 (16.72) | 0 (0.00) | 861 (13.42) | 910 (26.33) | 1165 (43.63) |
| Past year cancer | 678 (3.76) | 0 (0.00) | 206 (2.92) | 190 (5.35) | 282 (10.76) |
| Other chronic diseases | 0 (0.00) | ||||
| Ever diabetes | 3276 (22.32) | 0 (0.00) | 833 (18.29) | 1033 (35.69) | 1410 (56.63) |
| Ever chronic bronchitis or COPD | 1249 (8.51) | 0 (0.00) | 206 (4.48) | 280 (9.80) | 763 (32.59) |
| Ever asthma | 1369 (8.00) | 0 (0.00) | 281 (4.87) | 389 (10.45) | 699 (27.43) |
| Ever hepatitis | 327 (2.16) | 0 (0.00) | 63 (1.33) | 76 (2.35) | 188 (7.95) |
| Ever cirrhosis | 107 (0.67) | 0 (0.00) | 11 (0.12) | 19 (0.89) | 77 (2.96) |
| Ever high blood pressure | 6517 (38.80) | 0 (0.00) | 2127 (35.10) | 2188 (67.02) | 2202 (84.00) |
| Other health variables | |||||
| Self-rated Health | |||||
| Excellent or very good | 7615 (45.49) | 2843 (62.06) | 2818 (46.74) | 1340 (37.35) | 614 (21.99) |
| Good | 5227 (34.31) | 1062 (26.43) | 1886 (34.79) | 1247 (40.03) | 1032 (40.48) |
| Fair or poor | 2830 (20.20) | 454 (11.51) | 847 (18.47) | 625 (22.62) | 904 (37.53) |
| Past Year Mental Illness | |||||
| No | 14000 (88.70) | 4016 (91.84) | 5007 (89.42) | 2846 (88.00) | 2131 (82.00) |
| Yes | 1672 (11.30) | 343 (8.16) | 544 (10.58) | 366 (12.00) | 419 (18.00) |
| Medical cannabis use | |||||
| Any past-year cannabis use recommended by doctor | 296 (1.68) | 77 (1.80) | 102 (1.54) | 55 (1.57) | 62 (1.94) |
| All past-year cannabis use recommended by doctor | 211 (1.17) | 57 (1.29) | 64 (0.95) | 40 (1.17) | 50 (1.50) |
| Sociodemographics | |||||
| Race/Ethnicity | |||||
| Black/African American | 1350 (9.42) | 337 (8.79) | 536 (10.38) | 267 (8.45) | 210 (9.44) |
| Hispanic | 1107 (9.35) | 348 (10.25) | 448 (10.64) | 198 (8.81) | 113 (5.15) |
| Other | 1013 (6.52) | 297 (7.41) | 372 (6.74) | 192 (5.73) | 152 (5.34) |
| White | 12202 (74.71) | 3377 (73.54) | 4195 (72.23) | 2555 (77.01) | 2075 (80.07) |
| Sex | |||||
| Male | 7158 (45.43) | 1801 (40.92) | 2463 (45.84) | 1545 (46.67) | 1349 (51.19) |
| Female | 8514 (54.57) | 2558 (59.08) | 3088 (54.16) | 1667 (53.33) | 1201 (48.81) |
| Income | |||||
| <$20,000 | 1935 (14.27) | 535 (13.61) | 764 (15.87) | 303 (10.66) | 333 (16.12) |
| $20,000-$49,999 | 5088 (34.41) | 1383 (35.07) | 1817 (34.70) | 1012 (32.31) | 876 (35.17) |
| $50,000-$74,999 | 2809 (17.22) | 746 (15.94) | 970 (16.58) | 609 (19.30) | 484 (18.50) |
| $75,000+ | 5840 (34.10) | 1695 (35.39) | 2000 (32.84) | 1288 (37.73) | 857 (30.21) |
| Education | |||||
| High school graduate | 3657 (29.58) | 1068 (31.63) | 1369 (31.45) | 610 (23.30) | 610 (29.18) |
| Less than high school | 1444 (11.68) | 429 (12.18) | 579 (13.46) | 234 (8.91) | 202 (9.89) |
| Some college or associate degree | 4282 (27.51) | 1103 (25.21) | 1466 (26.24) | 933 (31.10) | 780 (30.36) |
| College graduate | 6289 (31.22) | 1759 (30.98) | 2137 (28.84) | 1435 (36.69) | 958 (30.57) |
| Employment | |||||
| Full time | 1623 (9.80) | 573 (12.25) | 582 (9.75) | 296 (9.42) | 172 (5.85) |
| Part time | 1836 (10.53) | 575 (12.99) | 644 (10.16) | 367 (10.43) | 250 (7.01) |
| Unemployed | 124 (1.00) | 40 (1.01) | 54 (1.17) | 14 (0.52) | 16 (1.16) |
| Other | 12089 (78.67) | 3171 (73.74) | 4271 (78.92) | 2535 (79.64) | 2112 (85.97) |
| Veteran Status | |||||
| Not veteran | 12903 (82.54) | 3761 (87.06) | 4649 (82.79) | 2574 (79.38) | 1919 (77.59) |
| Veteran | 2769 (17.46) | 598 (12.94) | 902 (17.21) | 638 (20.62) | 631 (22.41) |
| Lifetime arrest | |||||
| No arrest | 14135 (89.95) | 4003 (91.62) | 5010 (89.94) | 2903 (89.45) | 2219 (87.48) |
| Any arrest | 1537 (10.05) | 356 (8.38) | 541 (10.06) | 309 (10.55) | 331 (12.52) |
COPD = Chronic Obstructive Pulmonary Disease
Past-month tobacco and/or cannabis use prevalences by chronic disease status are presented in Table 2. Most (52.4%) reported former use of tobacco and/or cannabis, 31.0% reported never use, 10.9% tobacco-only, 4.1% cannabis-only, and 1.7% reported co-use of tobacco and cannabis. Co-use was reported by 12.5% of those who used tobacco in the past-month and 28.4% of those who used cannabis in the past-month. Former use consisted mostly of lifetime tobacco use or lifetime co-use, with only 4.1% of this group reporting former use of cannabis-only but never tobacco.
Table 2.
Tobacco/Cannabis Use Prevalence by Chronic Disease Status Among National Survey on Drug Use and Health (2021-2023) Respondents 65+ Years (N = 15,672)
| Full Sample | 0 Diagnoses | 1 Diagnosis | 2 Diagnoses | 3+ Diagnoses | |
|---|---|---|---|---|---|
| N (Weighted Row %) | |||||
| Current tobacco use (no lifetime cannabis use) | 1444 (10.90) | 424 (11.56) | 512 (10.83) | 265 (9.91) | 243 (11.08) |
| Current cannabis use (no lifetime tobacco use) | 659 (4.05) | 216 (4.77) | 199 (3.34) | 136 (4.48) | 108 (3.95) |
| Current use of both tobacco & cannabis | 246 (1.65) | 78 (2.16) | 76 (1.40) | 48 (1.48) | 44 (1.55) |
| Lifetime use of either tobacco/ cannabis | 8677 (52.44) | 2201 (47.12) | 3004 (51.27) | 1894 (56.18) | 1578 (60.45) |
| Never use of tobacco/cannabis | 4646 (30.95) | 1440 (34.39) | 1760 (33.16) | 869 (27.96) | 577 (22.96) |
In adjusted models (Table 3), higher lifetime chronic disease diagnoses were negatively associated with current co-use, tobacco-only, and cannabis-only use. The adjusted relative risk of co-use vs. former tobacco/cannabis was 0.47 (95% CI: 0.27, 0.83) for one diagnosis, 0.47 (95% CI: 0.27, 0.82) for two, and 0.36 (95% CI: 0.18, 0.72) for 3+, compared to no diagnoses. Similarly, respondents with a higher number of diagnoses were less likely to report tobacco-only and cannabis-only use (see Table 3 for further detail). There was no significant difference in co-use by past-year heart conditions or cancer, compared to those without.
Table 3.
Relationships Between Tobacco/Cannabis Use Categories and Clinical and Sociodemographic Characteristics Among National Survey on Drug Use and Health (2021-2023) Respondents 65+ Years (N = 15,672)
| Current co-use of tobacco and cannabis vs. former tobacco/cannabis | Current tobacco-only vs. former tobacco/cannabis | Current cannabis-only vs. former tobacco/cannabis | |
|---|---|---|---|
| aRRR (95% CI) | aRRR (95% CI) | aRRR (95% CI) | |
| Lifetime Chronic Disease | |||
| 0 | Reference | Reference | Reference |
| 1 | 0.47 (0.27, 0.83) | 0.77 (0.63, 0.93) | 0.64 (0.45, 0.91) |
| 2 | 0.47 (0.27, 0.82) | 0.72 (0.57, 0.90) | 0.76 (0.53, 1.08) |
| 3+ | 0.36 (0.18, 0.72) | 0.60 (0.46, 0.78) | 0.63 (0.44, 0.91) |
| Past Year Heart Condition | |||
| No | Reference | Reference | Reference |
| Yes | 0.78 (0.39, 1.55) | 0.76 (0.54, 1.07) | 0.92 (0.64, 1.34) |
| Past Year Cancer | |||
| No | Reference | Reference | Reference |
| Yes | 0.73 (0.24, 2.23) | 0.64 (0.42, 0.98) | 0.97 (0.52, 1.81) |
| Race | |||
| Black/African American | 1.94 (1.14, 3.29) | 1.20 (0.95, 1.51) | 1.47 (0.92, 2.34) |
| Hispanic | 1.00 (0.47, 2.11) | 0.40 (0.28, 0.60) | 1.10 (0.64, 1.91) |
| Other | 0.81 (0.34, 1.93) | 0.90 (0.53, 1.53) | 1.23 (0.65, 2.35) |
| White | Reference | Reference | Reference |
| Sex | |||
| Male | Reference | Reference | Reference |
| Female | 0.61 (0.38, 1.00) | 0.67 (0.57, 0.80) | 0.65 (0.51, 0.84) |
| Income | |||
| <$20,0000 | Reference | Reference | Reference |
| $20,000-$49,999 | 0.60 (0.32, 1.13) | 0.62 (0.48, 0.80) | 0.92 (0.53, 1.60) |
| $50,000-$74,999 | 0.55 (0.23, 1.30) | 0.51 (0.37, 0.71) | 1.03 (0.51, 2.08) |
| $75,000+ | 0.52 (0.22, 1.23) | 0.43 (0.30, 0.61) | 1.03 (0.62, 1.70) |
| Education | |||
| Less than high school | 0.99 (0.46, 2.12) | 1.53 (1.22, 1.93) | 0.39 (0.19, 0.83) |
| High school graduate | Reference | Reference | Reference |
| Some college or associate degree | 1.12 (0.65, 1.93) | 0.89 (0.69, 1.14) | 1.70 (1.14, 2.54) |
| College graduate | 0.59 (0.31, 1.13) | 0.52 (0.38, 0.71) | 1.73 (1.14, 2.64) |
| Employment | |||
| Full time | Reference | Reference | Reference |
| Part time | 1.60 (0.68, 3.76) | 1.08 (0.78, 1.51) | 1.37 (0.77, 2.45) |
| Unemployed | 1.12 (0.23, 5.61) | 1.41 (0.68, 2.93) | 1.72 (0.49, 6.03) |
| Other | 1.04 (0.49, 2.18) | 0.93 (0.69, 1.26) | 1.24 (0.78, 1.97) |
| Veteran status | |||
| Not veteran | Reference | Reference | Reference |
| Veteran | 1.05 (0.65, 1.70) | 0.88 (0.69, 1.12) | 0.55 (0.37, 0.81) |
| Self-rated health | |||
| Excellent or very good | Reference | Reference | Reference |
| Good | 2.31 (1.39, 3.86) | 1.43 (1.16, 1.76) | 0.82 (0.64, 1.07) |
| Fair or poor | 2.73 (1.39, 5.34) | 2.20 (1.70, 2.86) | 1.00 (0.73, 1.35) |
| Past year mental illness | |||
| No | Reference | Reference | Reference |
| Yes | 2.07 (1.31, 3.26) | 1.07 (0.84, 1.38) | 1.26 (0.88, 1.79) |
| Lifetime arrest | |||
| No arrest | Reference | Reference | Reference |
| Any arrest | 2.70 (1.76, 4.15) | 1.46 (1.20, 1.78) | 2.54 (1.80, 3.59) |
| Year | |||
| 2021 | Reference | Reference | Reference |
| 2022 | 0.65 (0.40, 1.05) | 0.77 (0.62, 0.96) | 1.20 (0.83, 1.74) |
| 2023 | 1.14 (0.73, 1.78) | 0.82 (0.65, 1.03) | 1.44 (1.09, 1.91) |
Note: Bolded values indicate statistical significance (p < 0.05)
Compared to excellent/very good health, co-use vs. former use was more likely for those reporting good health (aRRR=2.31, 95% CI: 1.39, 3.86) and reporting fair/poor health (aRRR=2.73, 95% CI: 1.39, 5.34). Those with past year mental illness (vs. no past year) were more likely to report co-use (aRRR=2.07; 95% CI: 1.31, 3.26) than former use. Differences in likelihood of co-use were also observed by race and lifetime arrest (Table 3). Unadjusted models are presented in Supplementary Table 1.
Discussion
In 2021-2023, one in six U.S. adults ages 65 and older reported past-month use of either tobacco or cannabis, and 1.7% reported past-month use of both. Notably, about one out of eight (12.5%) using tobacco in the past month reported cannabis co-use. Given that older adults are disproportionately impacted by tobacco morbidity and mortality (Kleykamp & Kulak, 2023; McAfee et al., 2021; U.S. Department of Health & Human Services, 2014), and cannabis co-use can impede tobacco cessation (Weinberger et al., 2018), results underscore co-use as a clinically meaningful behavior in this age group. Importantly, tobacco cessation among adults 65+ years might not be sufficiently addressed without considering concurrent cannabis-use. Accordingly, tobacco cessation efforts should routinely screen and address cannabis co-use for this age group.
Adults 65+ years with more lifetime chronic disease diagnoses were less likely to co-use, suggesting that chronic disease appears to promote cessation or reduction in tobacco (and co-use), likely via healthcare engagement. Comparing tobacco-only and cannabis-only use, tobacco-only use was consistently less likely among those with greater chronic disease burden, whereas cannabis-only use showed weaker and less consistent associations. Together, findings might reflect increased likelihood of tobacco cessation following diagnosed chronic disease. Diagnoses can increase the likelihood of health behavior change and can also indicate engagement with the healthcare system (and thus greater access to tobacco cessation advice and treatment). Consistently, prior research links medical diagnoses to reductions in alcohol and tobacco use (Xiang et al., 2016). Comparatively, cannabis use in this age group is motivated by heterogenous reasons (e.g., pain, insomnia, recreation/enjoyment) (Kaufmann et al., 2022; Reynolds et al., 2018; Thayer et al., 2026; Yang et al., 2022) and thus a chronic disease diagnosis may be more likely to motivate tobacco cessation than cannabis cessation.
In contrast to patterns observed for diagnosed chronic disease, perceived health status showed an opposite association with tobacco and cannabis use. Specifically, worse self-rated health was associated with higher co-use or tobacco-only than former use. This finding is consistent with well-documented negative health consequences of both substances, particularly tobacco (Han et al., 2018; U.S. Department of Health & Human Services, 2014). This apparent contradiction suggests that self-rated health and diagnosed disease may capture different dimensions of health status. Receiving a diagnosis requires some level of healthcare engagement, while self-reported physical health does not. Given that alleviating physical health symptoms (e.g., pain, insomnia) is the most common reason for cannabis use in older adults (Kaufmann et al., 2022; Reynolds et al., 2018; Thayer et al., 2026; Yang et al., 2022), a possible explanation is that individuals with tobacco-related health conditions may turn to cannabis (and thus co-use) to self-manage health conditions. Self-managing health conditions might be even more likely if an older adult’s symptoms are not being adequately addressed within the healthcare system. Given that poor self-rated physical health is a strong predictor of negative health outcomes, including mortality (Drame et al., 2023; Sekhon et al., 2026), targeted tobacco cessation support to older adults, particularly those co-using cannabis, is critical. Efforts to reach adults 65+ years who may be less connected to traditional healthcare settings – such as through community-based or internet-based platforms might be important for tobacco cessation among those co-using both products.
One in five individuals 65+ years who used cannabis in the past-year reported any recommendation from a doctor, which is notable in the context of recent reports of low cannabis-related discussion with providers among adults 65+ years (Mauro et al., 2026). In fact, older adults often report limited access to credible cannabis-related information (Fahey et al., 2025a; Kleidon et al., 2023), which is concerning due to potential risks. Although the impact of cannabis route of administration on tobacco cessation remains unknown, evidence suggests that inhaled cannabis use (vs. ingested) is associated with a higher likelihood of cannabis use disorder (CUD) (Pravosud et al., 2025) and increased risk for pulmonary harm (Minerbi et al., 2019). More frequent use and recreational use further increases CUD risk in this population (Pravosud et al., 2025). Given these risks, clinicians should educate adults 65+ years about safer patterns of use and promote safer use strategies from a harm reduction perspective, including less frequent use and avoiding smoking cannabis (Han & Moore, 2019). Clinicians can also mitigate functional risks associated with the psychoactive effects of THC by advising patients to avoid driving or engaging in activities that could increase fall risk following cannabis use or taking it with other psychoactive medications or substances (Han & Moore, 2019). Screening specifically for cannabis use is also critical for this population yet remains the exception among adults 65+ years (Han et al, 2025; Mauro et al., 2026). It is especially important to communicate that cannabis co-use may hinder tobacco cessation efforts and to recommend more intensive cessation intervention (e.g., combined pharmacotherapy and behavioral treatment). However, most geriatric-trained physicians report little knowledge and comfort in counseling older patients on cannabis use and medical education can reduce this knowledge gap (Jagasia et al., 2026). Overall, increasing clinician engagement and encouraging evidence-based cannabis harm reduction strategies will be increasingly important for this age group.
Past-month co-use was more likely among those with past-year mental illness, consistent with research finding this association among younger adults (Hindocha et al, 2020; Peters et al., 2012). Mental health concerns are commonly reported reasons for cannabis initiation (second to physical health symptoms) in older adulthood (Kaufmann et al., 2022; Reynolds et al., 2018). Co-use was also more likely among Black/African American individuals, males, those reporting any lifetime arrest and with less education. Similarly, prior studies have identified associations between criminal-legal exposure and polysubstance use in the U.S. adult population (Ford et al., 2022). Further, racially minoritized populations experience greater barriers to healthcare, and CUD treatment specifically, which exacerbates health-related disparities (Caraballo et al., 2022; Triguero et al., 2025) Together, these patterns suggest that co-use may be driven by intersecting mental health needs and social and structural determinants of health, positioning co-use as an indicator of compounded risk in older adulthood. Thus, findings highlight the need for targeted tobacco cessation and cannabis education dissemination among vulnerable older subpopulations to avoid exacerbating health-related disparities.
Strengths of the current study include the nationally representative sample and the unique focus on tobacco and cannabis co-use among U.S. older adults 65+ years. Limitations include self-reported measures, which might be biased towards the null due to under-reporting based on stigma-related concerns, social desirability, and recall bias. The sample of non-institutionalized U.S. population excluded older adults living in long-term care settings or experiencing homelessness not in shelters. While past-month blunt use prevalence reflects simultaneous administration (i.e., in the same product), our co-use definition was not able to distinguish simultaneous use from same-day sequential use or different-day use in the past month. Because cannabis patterns are associated with varying levels of clinical risk (e.g., simultaneous combustible use is associated with greater lung harms), future research should investigate how co-use patterns relate to long-term health outcomes (e.g., cardiovascular harms) (Abrams et al., 2018; Rusell et al., 2018).” Finally, NSDUH only assessed past-year provider-recommended cannabis use but not past-month recommendations. NSDUH also does not distinguish between the types of cannabis products and modes of administration in its assessment of past-month cannabis use in 2021, and state-level data is not publicly available. Future research should ascertain how co-use behavioral patterns (e.g., same delivery method, sequential use), product types, routes of administration, and motivations might be associated with unique health risks in this population.
Conclusion
Our study uniquely evaluated current prevalence estimates of past-month tobacco and cannabis among U.S. adults 65+ years, finding that most (52%) had formerly used tobacco and/or cannabis in their lifetime and 1 of 6 were continuing to use at least one of these products. As adults age into older adulthood, it will become increasingly important to promote tobacco cessation and to disseminate updated evidence-based information about cannabis use.
Supplementary Material
What this paper adds:
Assesses past-month tobacco and cannabis co-use prevalence among U.S. adults 65+ years in 2021-2023.
Examines the relationship between chronic disease and past-month co-use in this age group.
Examines sociodemographic characteristics associated with continued tobacco and cannabis co-use in this age group.
Application of study findings:
Approximately 1 in 8 adults 65+ years who use tobacco reported past-month cannabis co-use, underscoring notable co-occurrence of these behaviors.
This study informs clinical practice among this age group, including the importance of screening and accounting for cannabis co-use in tobacco cessation efforts.
Traditional healthcare-based tobacco cessation approaches may fail to reach adults 65+ years who are co-using cannabis.
Funding Statement:
Benjamin H. Han is supported by grants from the National Institute on Drug Abuse (K23DA043651, R21DA058404, R21DA060362 and the UC San Diego Sam and Rose Stein Institute for Research on Aging. Pia M. Mauro is supported by the National Institute on Drug Abuse (R01DA055606).
Footnotes
Ethical considerations: This analysis of de-identified public data was exempt from institutional review board review.
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability:
Data are publicly available.
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Associated Data
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Supplementary Materials
Data Availability Statement
Data are publicly available.