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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: Addict Behav. 2019 Oct 19;102:106153. doi: 10.1016/j.addbeh.2019.106153

Blunt Use and Menthol Cigarette Smoking: An Examination of Adult Marijuana Users

LaTrice Montgomery a, Dale S Mantey b, Erica N Peters c, Evan S Herrmann d, Theresa Winhusen e
PMCID: PMC6935044  NIHMSID: NIHMS1544637  PMID: 31704435

Abstract

Introduction

Use of menthol cigarettes remains highly prevalent among African American smokers and has increased among White and Hispanic/Latino smokers. Research is needed to examine if behavioral factors, such as marijuana use, are differentially associated with menthol cigarette use among racially/ethnically diverse samples of marijuana users.

Methods

Using data from the 2017 National Survey on Drug Use and Health, this study examined the association between past month marijuana (blunt versus non-blunt) and cigarette (non-menthol cigarette versus menthol cigarette versus no cigarette) use, as well as racial/ethnic differences in this relationship.

Results

Among all marijuana users (N = 5,137), 34.1% smoked blunts, 28.7% smoked non-menthol cigarettes and 18.0% smoked menthol cigarettes, with the highest rates of blunt (63.8%) and menthol cigarette (38.9%) use found among African American adults. Multinomial logistic regression analyses revealed a significant association between blunt use and non-menthol cigarette use (versus non-use) and menthol cigarette use (versus non-menthol cigarette and no cigarette use) among the full sample. When stratified by race/ethnicity, this finding was consistent for non-Hispanic White (n = 3,492) and partially consistent for Hispanic/Latino (n = 839) adults. However, among African American adults (n = 806), blunt use was not significantly associated with non-menthol cigarette use or menthol cigarette use.

Discussion

Blunt use is associated with increased odds of non-menthol and menthol cigarette use, but only among Hispanic/Latino and White adults. Examining racial/ethnic differences in the association between marijuana and tobacco use is important to understanding disparities and informing prevention and treatment interventions and drug policies.

Keywords: cigarette, tobacco, menthol, marijuana, blunt

INTRODUCTION

Despite substantial declines in adult cigarette smoking in the United States since 2000,1 nationally representative data indicate that menthol cigarette smoking prevalence has remained relatively unchanged over this time and increased among young adults (i.e., 18–25 year olds).2,3 Further, menthol cigarettes have increased from 26% of all cigarette sales in 2001 to 35% in 2016.4 This shift towards menthol cigarette smoking, particularly among young adults, presents a number of public health concerns given that menthol cigarettes, relative to non-menthol cigarettes, are associated with increased risk for nicotine dependence5,6,7 and long-term cigarette smoking8, thus increasing the risk for tobacco related illness.9 Given these epidemiological concerns, it is of significant public health importance to better understand menthol cigarette use behaviors.

Several risk factors for menthol cigarette smoking have been identified. Specifically, menthol cigarette smoking is highly prevalent among youth8,10 as well as African Americans.8 However, nationally representative data indicate that the proportion of menthol cigarette users has increased across race/ethnic groups3 while the overall prevalence of menthol cigarette smoking has increased among young adults (i.e., 18–25 years old).2 Changes in menthol cigarette smoking across race/ethnicity as well as increased prevalence among young adults indicate that traditional socio-demographic predictors of menthol cigarette smoking (e.g., age, race) provide only a partial understanding of menthol cigarette smoking behaviors. As such, research must examine other potential risk factors that may influence menthol cigarette smoking.

One plausible, but understudied risk factor for menthol cigarette smoking is marijuana use. Specifically, one study of nationally representative data of cigarette smokers revealed that the use of marijuana significantly increased among menthol cigarette smokers from 2005–2014.11 Some studies have found a link between the dual use of tobacco and marijuana and adverse health and social outcomes, such as increased exposure to combustion-related toxicants,12 associations with biomarkers of cardiovascular disease12,13 and adverse educational outcomes.14 Further, dual use of tobacco and marijuana is associated with greater rates of alcohol and other drug use.15 Despite the growing body of literature on tobacco and marijuana co-use, few of these studies have explicitly examined the link between menthol cigarettes and marijuana.11, 16,17

Previous studies have found substantial differences in the dual use of marijuana and menthol cigarettes across race/ethnicity and age.11 Specifically, in a national sample of cigarette smokers, African Americans (20.8%) had greater odds of dual use of marijuana and menthol cigarettes than non-Hispanic Whites (5.8%). However, among youth (12–17 year olds) and young adults (18–25 year olds), non-Hispanic Whites had greater odds of dual use of marijuana and menthol cigarettes than African Americans. Differences in dual use of marijuana and menthol cigarettes among cigarette smokers across socio-demographics indicate the need to examine the association between these behaviors between and within race/ethnic groups.

Beyond socio-demographic differences between dual users of marijuana and menthol cigarettes vs. non-dual users, menthol cigarette smokers differ from non-menthol cigarette smokers in method of marijuana use.11 Specifically, menthol cigarette smokers (73.6%) report significantly higher rates of marijuana ‘blunt’ use than non-menthol cigarette smokers (46.3%). Blunts are partially or fully hollowed-out large cigars, little cigars or cigarillos that are filled with marijuana. Several studies indicate lower harm perceptions towards marijuana blunt use, relative to smoking cigars as intended, and relative to other forms of tobacco.18–21 However, blunt use is associated with greater risk of both nicotine dependence (relative to cigar use) and marijuana use disorder (relative to other forms of marijuana use).11

Despite the negative health effects of both blunts and menthol cigarettes, both products are highly prevalent among cigarette and marijuana smokers.3,11 Several studies suggest that preference for flavored tobacco use may be a leading reason for the use of both products.2, 22–24 Further, both flavored cigars as well as menthol cigarettes have been aggressively marketed by the tobacco industry, especially among young adults and racial/ethnic minorities (e.g., African Americans; Hispanic/Latinos).25,26, 27

Study aims and hypotheses

This study aims to determine the association between blunt use and cigarette smoking behavior among a nationally representative sample of adult marijuana users. Further, this study will also examine the relationship between marijuana blunt use and cigarette smoking behavior, stratified by race/ethnicity. These subsample analyses are essential in understanding the complex relationship between marijuana use behaviors and cigarette smoking given known differences in marijuana blunt use28–31 as well as cigarette smoking behaviors32–34 by race/ethnicity.

First, we hypothesized that marijuana blunt use would be associated with increased odds of being a non-menthol cigarette smoker as well as a menthol cigarette smoker, relative to being a non-smoker, among the full sample. Further, we hypothesized that marijuana blunt use would be associated with increased odds of being a menthol cigarette smoker, relative to a non-menthol cigarette smoker, among the full sample. The examination of racial/ethnic differences in the association between marijuana blunt use and cigarette smoking behaviors was exploratory.

METHODS

Study sample and population

Data were from the 2017 National Survey on Drug Use and Health (NSDUH), an annual cross-sectional survey focused on substance use/abuse and other health-related behaviors in the United States. NSDUH utilizes multi-state area probability sampling to select nationally representative sample of the U.S. population aged 12 year or older. The current study examines a subsample of the NSDUH study population. Specifically, this study only examines non-Hispanic African American (n = 806), Hispanic/Latino (n = 839) and non-Hispanic White (n = 3,492) adults (i.e., 18 years of age or older) that reported any use of marijuana in the past 30-days and with complete data for all variables included in this study. The final sample of this study is n = 5,137. This study elected to exclude adolescent blunt users from analysis due to systematic differences in access to marijuana and tobacco products by age. Specifically, though several states have legalized medical and/or recreational marijuana, adolescents (i.e., those under 18 years of age) are prohibited from purchasing marijuana.35 Similarly, federal age restrictions prohibit the sale of tobacco products (e.g., cigars; cigarettes) to individuals under the age of 18 in all states.36

For this study, other racial/ethnic minorities (i.e., Asians, Native Hawaiian/Other Pacific Islander, American Indian or Alaska Native, or members of two or more races) were not included in these analyses, for two reasons. First, overall sample size as well as menthol and/or marijuana blunt use prevalence for each group limited the stability of any stratified analyses of these groups. Second, while other analyses consistently collapse these individuals into a single race/ethnic category (i.e., “other”), our study declined such coding due to the heterogeneity within and across these racial/ethnic groups. Specifically, categorizing these individuals in a single group allows for misinterpretation of any analyses.37 Further methodological details are available elsewhere.38

Measures

Cigarette smoking behaviors

Cigarette smoking status was the outcome variable in this analysis. Study participants were categorized into three mutually exclusive groups: non-smokers, non-menthol cigarette smokers, and menthol cigarette smokers. Classification was determined through two questions. First, all participants were asked “During the past 30 days, have you smoked part or all of a cigarette?” Individuals that responded “no” were considered non-smokers. Individuals that responded “yes” were subsequently asked “Were the cigarettes you smoked during the past 30-days menthol?” Participants that reported “no” were considered non-menthol cigarette smokers and those that reported “yes” were considered menthol cigarette smokers.

Marijuana use behaviors

Marijuana blunt use was the independent variable in this analysis. Specifically, participants who reported past month marijuana use were asked “On how many of the past 30-days did you smoke part or all of a cigar with marijuana in it?” Participants that reported 1 or more were considered “marijuana blunt users” while those that reported 0 of the past 30-days or that they had never used marijuana blunts were considered “marijuana non-blunt users” (referent group).

Socio-demographic variables

This study examined several socio-demographic variables. Participant age was categorized into four groups: 18–25 years old, 26–34 years old, 35–49 years old, and 50 years or older (referent group). Sex is a binary variable; males served as the referent group. Annual household income was categorized as: less than $20,000 per year, $20,000-$49,999 per year, $50,000-$74,999 per year, and $75,000 or more per year (referent group). Educational attainment was categorized into four groups: less than high school education, high school graduate, some college, and college graduate (referent group).

Substance use and mental health variables

Past 30-day alcohol use was a covariate in this analysis. Study participants were categorized into four mutually exclusive categories: nonusers (referent); light alcohol use, binge alcohol use, and heavy alcohol use. Binge alcohol use was defined as having 5 or more alcoholic beverages on the same occasion on at least 1 but not more than 4 days in the past 30-days. Heavy alcohol use was defined as binge alcohol use on 5 or more days in the past 30 days. Light alcohol use was any alcohol that did not qualify for binge or heavy alcohol use.38 Illicit use of drugs other than marijuana was assessed by self-reported use of any of the following substances in the past 30-days: hallucinogens, inhalants, tranquilizers, cocaine, heroin, opioid pain relievers, stimulants, or sedatives. These covariates were added to the statistical model as each has been linked to adult marijuana blunt use across race/ethnic groups.29

Given the link between psychiatric distress and menthol cigarette use,39,40 this study also controlled for self-reported history of a major depressive episode (MDE) in the past 12-months. Study participants were considered to have had an MDE in the past 12-months if they reported five or more criteria for a MDE in the past 12-months and one of these five or more criteria were a depressed mood or loss of interest/pleasure in daily activities.

Data analysis

Two multinomial logistic regression analyses were conducted to examine the association between marijuana blunt smoking and cigarette smoking behavior. The first multinomial logistic regression analysis assigned non-smokers as the referent group. This analysis examined the association between past 30-day marijuana blunt use and each type of cigarette smoking (i.e., non-menthol or menthol), relative to non-smoking. The second multinomial logistic regression analysis assigned non-menthol cigarette smokers as the referent group. This analysis examined the association between past 30-day marijuana blunt use and menthol cigarette smoking, relative to non-menthol cigarette smoking.

These multinomial logistic regression analyses were replicated, stratified by race/ethnicity. Specifically, the relationship between past 30-day marijuana blunt use and each type of cigarette smoking (i.e., non-menthol or menthol), relative to non-smoking was examined among non-Hispanic Whites (hereafter referred to as Whites), Hispanic/Latinos, and non-Hispanic African Americans (hereafter referred to as African Americans). Similarly, the relationship between past 30-day marijuana blunt use and menthol cigarette smoking, relative to non-menthol cigarette smoking, was examined among Whites, Hispanic/Latinos, and African Americans.

The permutation of these analyses allows for a comprehensive examination of marijuana blunt use across cigarette smoking behaviors. Specifically, this methodology allows for three sets of comparisons: 1) non-smokers vs. non-menthol cigarette smokers, 2) non-smokers vs. menthol cigarette smokers, and 3) non-menthol cigarette smokers vs. menthol cigarette smokers. Further, stratified analyses allow for the examination of these relationships across diverse populations.

Data were weighted to be representative of the U.S. population. Nationally representative estimates of prevalence for each outcome and covariates were computed for the full sample as well as each racial/ethnic group. Statistical models of the full sample included all covariates. Models stratified by race/ethnicity included all covariates with the obvious exception of race/ethnicity. For the purposes of this study, relative risk ratios (RR) and 95% confidence intervals (CI) were computed and recorded. All analyses were conducted using STATA 14.0 (College Station, TX).

RESULTS

Descriptive statistics

Among the full sample, 34.1% reported past 30-day marijuana blunt use. As shown in Table 1, several descriptive differences in marijuana blunt use were observed. For example, use of marijuana blunts was more prevalent among African American marijuana users (63.8%) than White (25.8%) and Hispanic/Latino (42.9%) marijuana users. Similarly, younger marijuana users reported the greatest prevalence of past 30-day marijuana blunt use. Specifically, more than half of 18–25 year olds (57.0%) reported marijuana blunt use while only 37.5% of 26–34 year olds, 26.3% of 35–49, and 8.4% of 50+ year olds reported using marijuana blunts in the past 30-days. Past 30-day marijuana blunt use was lowest among individuals with a college education (16.1%) and ranged from 38.7% to 41.1% among individuals with less than a college education.

Table 1:

Demographic Characteristics of Adult Marijuana Users, Stratified by Marijuana Use and Cigarette Smoking Behavior

Marijuana Use Behavior (n = 5,137) Cigarette Smoking Behavior (n = 5,137)
Blunt Marijuana Use (95% CI) Non-Blunt Marijuana (95% CI) Non-Smoker (95% CI) Smoker, non-menthol (95% CI) Smoker, menthol (95% CI)
Percent of Sample 34.1% (32.4 – 35.9) 65.9% (64.1 – 67.6) 53.3% (51.5 – 55.1) 28.7% (27.0 – 30.5) 18.0% (16.7 – 19.3)
Race/Ethnicity
Non-Hispanic White 25.8% (24.1 – 27.6) 74.2% (72.4 – 75.9) 52.8% (50.6 – 55.0) 34.4% (32.2 – 36.6) 12.8% (11.7 – 14.1)
African American 63.8% (59.1 – 68.3) 36.2% (31.7 – 40.9) 52.3% (46.6 – 58.0) 8.8% (6.0 – 12.8) 38.9% (33.7 – 44.3)
Hispanic/Latino 42.9% (38.2 – 47.7) 57.1% (52.3 – 61.8) 56.8% (52.1 – 61.3) 22.3% (18.0 – 27.3) 21.0% (16.9 – 25.7)
Age Category
18–25 years old 57.0% (54.3 – 59.6) 43.0% (40.4 – 45.7) 54.4% (52.0 – 56.7) 25.8% (24.1 – 27.6) 19.8% (18.1 – 21.6)
26–34 years old 37.5% (33.9 – 41.2) 62.5% (58.8 – 66.1) 47.1% (43.6 – 50.5) 30.7% (27.5 – 34.1) 22.2% (19.3 – 25.5)
35–49 years old 26.3% (22.7 – 30.2) 73.7% (69.8 – 77.3) 47.7% (43.0 – 52.4) 31.5% (27.6 – 35.8) 20.8% (17.2 – 25.0)
50+ years old 8.4% (6.5 – 10.8) 91.6% (89.2 – 93.5) 64.0% (58.8 – 68.8) 27.6% (23.5 – 32.1) 8.4% (6.1 – 11.6)
Sex
Male 34.5% (32.1 – 37.0) 65.5% (63.0 – 67.9) 52.6% (50.3 – 54.8) 30.5% (28.2 – 32.9) 16.9% (15.3 – 18.8)
Female 33.5% (31.0 – 36.0) 66.5% (64.0 – 69.1) 54.5% (51.4 – 57.5) 25.9% (23.8 – 28.1) 19.6% (17.7 – 21.8)
Annual Income
Less than $20,000 42.4% (38.7 – 46.2) 57.6% (53.8 – 61.3) 39.0% (34.6 – 43.5) 36.6% (32.9 –40.5) 24.4% (20.9 – 28.4)
$20,000 – 49,999 36.2% (33.2 – 39.2) 63.9% (60.8 – 66.8) 50.7% (47.1 – 54.3) 28.9% (25.1 – 33.0) 20.4% (17.9 – 23.4)
$50,000 – 74,999 36.5% (31.9 – 41.3) 63.5% (58.7 – 68.1) 52.0% (46.6 – 57.3) 30.3% (25.4 – 35.8) 17.7% (14.2 – 21.7)
$75,000 or more 25.0% (22.3 – 27.9) 75.0% (72.1 – 77.7) 66.8% (62.9 – 70.5) 22.1% (19.2 – 25.4) 11.1% (9.4 – 13.0)
Education
Less than HS 41.1% (35.3 – 47.2) 58.9% (52.8 – 64.7) 31.9% (27.0 – 37.2) 39.4% (34.2 – 44.8) 28.7% (23.5 – 34.5)
HS Graduate 41.1% (37.6 – 44.7) 58.9% (55.4 – 62.4) 43.8% (40.4 – 47.2) 34.1% (30.4 – 38.0) 22.1% (19.4 – 25.1)
Some College 38.7% (35.6 – 41.9) 61.3% (58.1 – 64.4) 54.8% (51.9 – 57.6) 27.4% (24.9 – 30.0) 17.9% (15.8 – 20.1)
College Graduate 16.1% (13.1 – 19.7) 83.9% (80.3 – 86.9) 71.7% (67.7 – 75.4) 19.8% (17.0 – 23.0) 8.5% (6.5 – 11.0)
Major Depression
No 33.5% (31.7 – 35.4) 66.5% (64.6 – 68.3) 54.3% (52.2 – 56.4) 28.3% (26.6 – 30.0) 17.4% (15.9 – 19.0)
Yes 37.3% (32.1 – 42.8) 62.7% (57.2 – 67.9) 47.4% (42.5 – 52.20 31.3% (26.6 – 36.5) 21.3% (18.0 – 25.2)
Illicit Drug Use
No 31.1% (29.2 – 33.1) 68.9% (66.9 – 71.0) 57.4% (55.2 – 59.5) 26.0% (24.1 – 27.9) 16.7% (15.2 – 18.2)
Yes 47.1% (42.9 – 51.4) 52.9% (48.6 – 57.1) 35.5% (32.1 – 38.9) 40.7% (37.1 – 44.5) 23.8% (23.4 – 27.6)
Alcohol Use
None 30.8% (27.2 – 34.8) 69.2% (65.2 – 72.8) 48.8% (43.9 – 53.8) 31.2% (27.1 – 35.7) 20.0% (16.6 – 23.8)
Light 28.5% (24.9 – 32.4) 71.5% (67.6 – 75.1) 63.4% (59.0 – 67.6) 22.1% (18.9 – 25.6) 14.5% (11.6 – 18.0)
Binge 40.0% (37.3 – 42.8) 60.0% (57.2 – 62.7) 53.5% (50.3 – 56.7) 28.2% (25.2 – 31.4) 18.3% (16.3 – 20.5)
Heavy 33.7% (29.7 – 38.0) 66.3% (62.0 – 70.3) 45.1% (41.0 – 49.2) 35.2% (31.7 – 38.9) 19.7% (16.9 – 22.9)
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Among the full sample of marijuana users, 53.3% did not smoke cigarettes, 28.7% smoked non-menthol cigarettes, and 18.0% smoked menthol cigarettes (displayed in Table 1). Cigarette smoking prevalence did not vary substantially by race/ethnicity, ranging from 43.2% among Hispanic/Latino marijuana users to 47.7% among African American marijuana users. However, there were substantial differences in the type of cigarettes smoked by race/ethnicity. Specifically, among cigarette smokers, 78.8% of Whites smoked non-menthol cigarettes and 27.2% smoked menthol cigarettes. Conversely, only 18.4% of African Americans smoked non-menthol cigarettes while 81.6% smoked menthol cigarettes. Prevalence of non-menthol cigarette (51.5%) and menthol cigarette (48.5%) smoking was evenly distributed among Hispanic/Latinos.

Among all marijuana blunt users, 30.3% also smoked menthol cigarettes. However, this distribution varied substantially by race/ethnicity. Specifically, 42.3% of African American marijuana blunt users also smoked menthol cigarettes. Conversely, only 32.0% of Hispanic/Latino and 23.3% of white marijuana blunt users also smoked menthol cigarettes.

Among all non-marijuana blunt users, 29.0% also smoked non-menthol cigarettes. However, 32.6% among white non-marijuana blunt users also smoked non-menthol cigarettes, compared to only 21.7% of Hispanic/Latino and 6.5% of African American non-marijuana blunt users.

The distribution of cigarette smoking behavior by marijuana use behavior is displayed in Table 2 for the full sample and stratified by race/ethnicity.

Table 2:

Cigarette Smoking Behavior by Marijuana Use Behavior for Full Sample and Stratified by Race/Ethnicity

Cigarette Smoking Behavior (n = 5,137)
Non-Smoker (95% CI) Smoker, non-menthol (95% CI) Smoker, menthol (95% CI)
Full Sample
Blunt Marijuana Use 41.6% (38.5 – 44.8) 28.1% (25.3 – 31.1) 30.3% (27.6 – 33.2)
Non-Blunt Marijuana 59.4% (56.9 – 61.8) 29.0% (27.2 – 31.0) 11.6% (10.1 – 13.4)
Non-Hispanic White
Blunt Marijuana Use 37.2% (33.9 – 40.6 39.5% (35.9 – 43.2) 23.3% (20.3 – 26.6)
Non-Blunt Marijuana 58.2% (55.2 – 61.2) 32.6% (30.1 – 35.2) 9.2% (7.9 – 10.7)
African American
Blunt Marijuana Use 47.6% (41.6 – 53.7) 10.1% (6.5 – 15.2) 42.3% (37.0 – 47.8)
Non-Blunt Marijuana 60.6% (49.4 – 70.7) 6.5% (3.0 – 13.7) 32.9% (23.9 – 43.3)
Hispanic/Latino
Blunt Marijuana Use 44.9% (38.0 – 52.1) 23.0% (17.0 – 30.5) 32.0% (24.7 – 40.4)
Non-Blunt Marijuana 65.6% (59.6 – 71.2) 21.7% (16.1 – 28.6) 12.7% (8.4 – 18.6)
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Marijuana blunt use and cigarette smoking behaviors

As seen in Table 3, marijuana blunt smokers had 1.52 (95% CI: 1.25 −1.86) greater relative risk of being a non-menthol cigarette smoker and 2.51 (95% CI: 1.95 – 3.24) greater relative risk of being a menthol cigarette smoker, compared to a non-smoker, when adjusting for all covariates. Marijuana blunt smokers also had 1.65 (95% CI: 1.26 – 2.16) greater relative risk of being a menthol cigarette smoker compared to a non-menthol cigarette smoker.

Table 3:

Multinomial Logistic Regression Models of Blunt Use and Cigarette Smoking Behavior Among Full Sample (n=5,137)

Non-Smoker Smoker, non-menthol Smoker, menthol
Relative Risk Ratio 95% Confidence Interval Relative Risk Ratio 95% Confidence Interval Relative Risk Ratio 95% Confidence Interval
Non-Smokers as Referent
Blunt Marijuana Use 1.00 (Ref) 1.52*** (1.25 – 1.86) 2.51*** (1.95 – 3.24)
Non-Menthol Cigarette Smokers as Referent
Blunt Marijuana Use --- 1.00 (Ref) 1.65*** (1.26 – 2.16)
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All models adjusted for age, sex, education, income, major depression, alcohol use and use of illicit drugs other than marijuana.

Bold indicates statistical significance

***

p < .001.

Subsample analyses were conducted, stratified by race/ethnicity. As seen in Table 3, White marijuana blunt smokers had 1.56 (95% CI: 1.21 – 2.01) greater relative risk of being a non-menthol cigarette smoker and 2.68 (95% CI: 1.92 – 3.74) greater relative risk of being a menthol cigarette smoker, compared to a non-smoker, when adjusting for all covariates. White marijuana blunt smokers also had 1.72 (95% CI: 1.27 – 2.31) greater relative risk of being menthol cigarette smokers compared to non-menthol cigarette smokers. Similarly, Hispanic/Latino marijuana blunt smokers had 3.58 (95% CI: 1.85 – 6.92) greater relative risk of being a menthol cigarette smoker, compared to a non-smoker, when adjusting for all covariates. However, marijuana blunt smoking was not associated with greater odds being a non-menthol cigarette smoker compared to a non-smoker, among Hispanic/Latinos, when adjusting for all covariates. Finally, marijuana blunt smoking was not associated with greater odds of being a non-menthol cigarette smoker (relative to a non-smoker) or menthol cigarette smoker (relative to a non-smoker or non-menthol cigarette smoker) among African Americans when adjusting for all covariates.

DISCUSSION

Similarly to findings among adolescents41,42 and African American young adults from California,43 the current study revealed a significant association between marijuana blunt use and cigarette smoking among a nationally representative sample of US adults. Specifically, past 30-day marijuana blunt use was associated with higher rates of both past 30-day non-menthol and menthol cigarette smoking among adult marijuana users. Several reasons have been proposed for the dual use of tobacco products and marijuana, including an enhanced reward effect when marijuana and nicotine are combined, as well as to counteract the sedative effects of marijuana.44 Moreover, menthol cigarettes contain flavors and compounds that have anti-inflammatory and anesthetic effects which may ease the inhalation of marijuana smoke.45Given that many marijuana blunt smokers engage in “blunt chasing”, or closely following their marijuana blunt use with tobacco46,, 47, marijuana blunt use in particular poses an increased risk of cigarette and other tobacco product (e.g., cigars) use. In light of the high prevalence of marijuana and tobacco co-use found among both adolescents and adults15,48–50, there is no surprise that the use of marijuana, namely blunts, was strongly associated with non-menthol and menthol cigarette smoking.

This study of adult marijuana users presents two innovative findings. First, past 30-day marijuana blunt users had greater odds of being menthol cigarette smokers, relative to non-menthol cigarette smokers. Preference for flavored tobacco products may be a factor leading to this relationship. Specifically, marijuana blunt use frequently occurs via flavored cigar products.2,24 Further, menthol is the only legally available characterizing flavor of combustible cigarettes. Given that both tobacco22,23 and marijuana blunt users2,24 frequently cite the availability of flavors as a reason for use, it is plausible to suggest the availability of flavored tobacco products is a leading factor in the relationship found in this study.

Second, this study also found important racial/ethnic differences in the relationship between these behaviors. For example, among White users, past 30-day marijuana blunt use was associated with increased odds of both past 30-day non-menthol cigarette smoking and menthol cigarette smoking, relative to non-smoking. Further, these marijuana blunt users had greater odds of menthol cigarette smoking, relative to non-menthol cigarette smoking. Among Hispanic/Latino adults, past 30-day marijuana blunt use was associated with greater odds of menthol cigarette smoking, relative to both non-smoking and non-menthol cigarette smoking. However, there was no statistical relationship between past 30-day marijuana blunt use and non-menthol cigarette smoking (relative to non-smoking or menthol cigarettes). Furthermore, among African American adults, marijuana blunt use was not significantly associated with non-menthol cigarette use (versus non-smokers and menthol cigarette use) or menthol cigarette use (versus non-smokers and menthol cigarette smokers). Given the recent increases in menthol cigarette smoking among Whites and Hispanic/Latinos,2,27 the present findings suggest the need to further explore the role of marijuana blunt use on changing trends in adult tobacco use in the United States and to consider variations by race/ethnicity.

Although past 30-day marijuana blunt (63.8%) and menthol cigarette (38.9%) use were highest among African American adults in the sample, findings suggest that marijuana blunt use is not associated with cigarette use among African Americans in the same way that it is for White and Hispanic/Latino adults. Previous studies have demonstrated a link between cigarette use and marijuana blunt use among African American adults. For instance, Montgomery and Mantey29 found that current cigarette users had increased odds (AOR: 3.96) of current marijuana blunt use compared to non-current cigarette users. However, previous work in this area has primarily included marijuana blunt use as an outcome variable in analyses and has mostly focused on outcomes among samples of cigarette smokers.11 In contrast, the current study includes marijuana blunt use as a predictor of cigarette use behaviors among marijuana users. Although all of the aforementioned studies, including this one, were cross-sectional and unable to test temporal causation, it is plausible that non-menthol and menthol cigarette smokers might be at higher risk of smoking marijuana blunts relative to non-blunt marijuana use, whereas marijuana blunt smoking does not impact cigarette use among African American marijuana users. Given that African Americans are more likely to report marijuana blunt use than other racial/ethnic groups51, it is possible that the exposure to nicotine/flavors in marijuana blunt wraps among African Americans might curb the appeal of additional nicotine/flavor exposure from non-menthol and menthol cigarettes. Moreover, among a sample of young African American males, marijuana (71%) and marijuana blunt (48%) smokers believed that marijuana blunts were safer than cigarettes because they are more natural and less addictive.20 Therefore, African American marijuana blunt users might be less inclined to smoke cigarettes due to these beliefs. Additional research is needed to explore the relationship between marijuana blunts and cigarette use among racially diverse adults.

Although this study has several strengths, including the use of a national dataset and a focus on significant public health problems (i.e., marijuana blunt and menthol cigarette use), a few limitations should be noted. First, this is a cross-sectional study which limits the ability to infer causation. Second, the NSDUH only allows for a comparison between marijuana blunt users and a broad category of non-blunt marijuana users. The methods of marijuana administration among non-blunt marijuana users in the sample are unknown. Future studies should include specific types of non-blunt marijuana use to determine if other methods of administration (e.g., vaping) impact cigarette use behaviors. Third, given the heterogeneity among African American, Hispanic/Latino and White individuals (e.g., gender differences in prevalence and correlates of blunt and menthol cigarette use within racial/ethnic groups)29,52, it is important to conduct additional studies to determine if these findings hold true among subgroups of each population.

Despite these limitations, findings from this study emphasize the importance of assessing and recognizing differences in socio-demographic characteristics, such as race, when assessing the correlates of cigarette use. This is especially important when considering flavored cigarette use given the aggressive marketing tactics of the tobacco industry in predominately minority communities. Moreover, marijuana blunt use has origins in the African American community and has been promoted through popular cultural artistic channels53. Therefore, marijuana blunt use has a unique socio-historical context in minority communities that might influence how they are used and experienced by minorities. Findings from this study suggest that while there is an overall association between marijuana blunt use and non-menthol and menthol cigarette use, this relationship might not exist among African American adults. Therefore, marijuana blunt use and cigarette use behaviors might be two increasingly prevalent stand-alone behaviors that are influenced by other factors in this subpopulation. A limited number of studies have identified correlates, mostly social and cultural, of menthol cigarette use among African Americans (e.g., parent’s menthol smoking, a belief that most African Americans smoke menthol cigarettes).54 The lack of an association found in this study highlights the need to continue to assess risk and protective factors for menthol cigarette use among African American adults. Moreover, additional studies are needed to further examine the increased risk of regular and menthol cigarette use among White and Hispanic/Latino adult marijuana users, as well as to inform prevention and treatment interventions and marijuana and tobacco policies.

Highlights.

  • Menthol cigarette smoking is increasing among racial/ethnic minority adults

  • Blunt use was associated with increased menthol cigarette use

  • When stratified by race, this association was found among White and Hispanic adults

  • No association between blunt and menthol cigarette use among African Americans

  • The impact of blunt use on menthol cigarette smoking varies by race

Footnotes

Conflict of Interest

All authors declare that they have no conflicts of interest.

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