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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: J Addict Med. 2020 Sep-Oct;14(5):e170–e174. doi: 10.1097/ADM.0000000000000652

Factors Associated with Cannabis Use Among African American Nondaily Smokers

Dana Rubenstein 1, Elizabeth R Aston 1,2, Nicole L Nollen 3, Matthew S Mayo 4, Alexandra R Brown 4, Jasjit S Ahluwalia 1,2
PMCID: PMC8376225  NIHMSID: NIHMS1712322  PMID: 32187115

Abstract

Objectives:

Cannabis and tobacco dual use is a growing concern in the US, especially among African Americans (AAs). Dual use increases nicotine dependence and poses negative health effects. Despite decreasing numbers of people who smoke daily, nondaily smokers (NDS) are increasing. Polytobacco use, including blunt use, is higher in AA NDS than AAs who smoke daily. This study examined factors associated with cannabis use among AA NDS.

Methods:

Adult AA NDS participated in a randomized controlled trial (N = 278) for smoking cessation. A subset of this sample (n = 262; mean age = 48.2 years; 50% male) was analyzed to identify correlates of cannabis use. Logistic regression assessed the associations of demographic, smoking-related, and psychosocial variables with cannabis use.

Results:

Participants smoked cigarettes on an average of 18 days of the last 30 and used 4.5 cigarettes on smoking days. Of the participants analyzed, 38% used cannabis, including blunts (i.e., cigars hollowed out filled with cannabis) at baseline. Cannabis use was associated with polytobacco product use not including blunts (OR = 2.11, 95% CI [1.18–3.77], p = .012), depressive symptoms (OR = 1.22, 95% CI [1.05–1.42], p = .011), and younger age (OR = 0.97, 95% CI [0.94–0.99], p = .004).

Conclusions:

Rates of cannabis and tobacco dual use in our sample exceed national rates. Dual use poses harmful health effects that exceed the risk of either substance alone. Findings will inform future work in tailoring treatments to vulnerable groups of people who use both tobacco and cannabis.

Keywords: Tobacco, cigarettes, cannabis, racial/ethnic minorities

Introduction

With increasing legalization, acceptability, and access to cannabis in the United States, the dual use of cannabis and tobacco is a growing concern. Dual use of tobacco and cannabis is often defined as past 30-day use of both substances (Schauer et al., 2015). This may take the form of co-administration, where cannabis and tobacco are combined in products such as blunts (cigars hollowed out and filled with cannabis) and smoked together, simultaneous use, where people use both substances on the same occasion but as separate products, or simply past 30-day use of both substances on separate days. Reasons for dual use include environmental factors, a potential shared route of administration (e.g., smoking), social contexts, and synergistic effects (Agrawal et al., 2012). In the past decade, rates of dual use of cannabis and tobacco have increased such that over 5% of the US population uses both substances (Schauer et al., 2015). In particular, the rate of past 30-day cannabis use among people who currently use tobacco has increased from 14% in 2004 to 18% in 2012 (Schauer et al., 2015).

The dual use of cannabis and tobacco poses significant risk to users. A number of studies have shown that the use of cannabis among tobacco users increases the risk of developing higher levels of nicotine dependence (Agrawal et al., 2012). Furthermore, using both cannabis and tobacco presents significant additive health risks that surpass the risk of either substance alone, such as more severe respiratory effects and higher carbon monoxide exposure (Meier and Hatsukami, 2016).

Specific groups such as African Americans (AAs) may be at heightened risk of dual use. Studies have found significant associations between tobacco and cannabis dual use and black or AA racial/ethnic identity (Schauer et al., 2015; Cohn et al., 2016). A recent paper analyzing data from the National Survey on Drug Use and Health (NSDUH) reported that 19% of surveyed AAs used cannabis in the past 30 days, while 28% of AAs used both cannabis and tobacco (Montgomery, 2015).

AAs are also more likely to be nondaily smokers (NDS) (Trinidad et al., 2009). NDS smoke tobacco on some but not all days. NDS make up an increasing proportion of US smokers, constituting 43% of all adults who smoke in the US (NSDUH, 2018). NDS are at risk for the same health consequences as those who smoke daily, yet are often overlooked in clinical care and research (Nollen et al., 2019). NDS use polytobacco products (tobacco products other than cigarettes, such as cigars or smokeless tobacco) at higher rates than light smokers (Reyes-Guzman et al., 2017), and AA NDS use polytobacco products more than AAs who smoke daily (Okuyemi et al., 2004). This is especially important in understanding the dual use of cannabis and tobacco, as AAs use blunts more than any other racial/ethnic group (Montgomery, 2015; Montgomery and Ramo, 2017).

Given the nuances of nondaily smoking and substance use in AAs, it is important to understand the factors associated with cannabis and tobacco dual use in AA NDS. The aim of this study was to examine demographic, psychosocial, and tobacco-related variables associated with cannabis use among AA NDS. Based on previous research, we hypothesized that in relation to those who only use tobacco, people who use both cannabis and tobacco would (a) be more likely to be male (Corral et al., 2013; Schauer et al., 2015), (b) be more likely to be younger (Montgomery, 2015; Schauer et al., 2015; Montgomery et al., 2019), (c) have higher rates of alcohol misuse (Schauer et al., 2015), (d) have more depressive symptoms (Cohn et al., 2016), and (e) be more likely to be polytobacco users (not including blunts) (Cobb et al., 2018).

Methods

Design

This is a secondary analysis of baseline data from a recently completed Randomized Controlled Trial (RCT) conducted at the University of Kansas Medical Center that examined smoking cessation treatments among AA adult NDS (Nollen et al., 2020). In this study, AA NDS were randomized to either smoking cessation counseling alone or smoking cessation counseling plus nicotine replacement therapy, in order to compare the effectiveness of the two treatments. Treatment in both groups lasted for 12 weeks, and the primary outcome was biochemically-verified abstinence at week 12. All study visits took place at the University of Kansas Medical Center or Swope Health Central, a Federally Qualified Health Center that serves predominately AA patients. The study procedures were approved and monitored by the University of Kansas Medical Center Institutional Review Board and all participants gave informed consent to participate in the study.

Participants

Study participants (N = 278) were non-Hispanic AAs over 18 years old who had smoked at least 100 lifetime cigarettes, and did not use polytobacco products on a daily basis. They smoked cigarettes on 4–27 of the last 30 days for ≥ 3 months (Shiffman et al., 2012; Shiffman et al., 2014; Shiffman et al., 2019). Participants were interested in quitting smoking and had no contraindications to nicotine replacement therapy (NRT). Of the total sample, one participant did not provide data on cannabis use and 15 others did not meet criteria for NDS, resulting in a final sample size of n = 262.

Measures

Outcome variable

Non-blunt cannabis use was assessed with a baseline question adapted from the National Survey on Drug Use and Health (NSDUH), “During the past 30 days, on how many days did you use marijuana not including blunts? Blunts are hollowed out cigars filled with marijuana.” (NSDUH, 2018) Answers were dichotomized, with responses of 1–30 days representing current cannabis use and responses of 0 days representing no current cannabis use. Blunt use was assessed using Timeline Follow-Back (TLFB) (Brown et al., 1998) interview data. Blunt use was defined by at least one reported day of blunt use in the past 30 days. Past 30-day cannabis use included past 30-day non-blunt cannabis use and/or blunt use.

Descriptive Variables

Demographics

Demographic questions in the baseline survey assessed participants’ age, sex, cohabitation status, employment status, educational level, health care coverage, poverty level, housing status, and perceived health.

Psychosocial Variables

A two-item depression-screener– the Patient Health Questionnaire (PHQ-2)– assessed participants’ depressive symptoms by asking how frequently respondents had been bothered by “Little interest or pleasure in doing things” and “Feeling down, depressed or hopeless” over the past two weeks (Kroenke et al., 2003). Both questions were scored from 0–3, and total scores of 3 or higher indicated possible depression.

Alcohol misuse among participants was evaluated via the three-question Alcohol Use Disorders Identification Test (AUDIT-C), which has demonstrated validity across racial/ethnic groups (Whites, Hispanics, and African Americans) (Frank et al., 2008). This questionnaire assessed heavy drinking and alcohol misuse (e.g. “How often do you have six or more drinks on one occasion”), with total scores ranging from 0–12 (Bush et al., 1998). Alcohol misuse was indicated by a score of 3 or greater for women and 4 or greater for men.

Past 30-day prescription pain reliever use was assessed with a baseline question adapted from NSDUH (NSDUH, 2018). Responses were dichotomized into past 30-day prescription pain reliever user and non-user.

Tobacco-Related Variables

Tobacco product use was assessed using the 30-day TLFB. Participants were asked to recall the number of cigarettes, hand rolled cigarettes, little cigars, cigarillos, full size cigars, blunts, pipes, bidis, smokeless tobacco, and hookah used for each of the past 30 days at various timepoints of the trial. All tobacco products other than cigarettes and blunts were combined to represent polytobacco use. NDS are a heterogeneous group consisting of some people who began smoking daily (converted NDS) and transitioned to less frequent use and others who initially used cigarettes on a nondaily basis (native NDS) (Shiffman et al., 2012; Scheuermann et al., 2015). Thus native or converted NDS status was assessed via the baseline question, “Has there ever been a time in your life when you smoked cigarettes on all days of the month. Specifically, have you ever smoked at least one cigarette every day for 30 days in a row for 6 months or more?”

Nicotine dependence was assessed at baseline through the question, “How soon after you wake up do you smoke your first cigarette?” Time to first cigarette was dichotomized into within 30 minutes of waking and after 30 minutes of waking. Dependence motives at baseline were also summarized via the Brief Wisconsin Inventory of Smoking Dependence Motives (Brief WISDM) (Smith et al., 2010).

Data Analysis

Baseline demographic, psychosocial, and smoking-related characteristics were summarized using descriptive statistics. Results for continuous variables were expressed as means (standard deviations), while categorical variables were reported in frequencies (percentages). We utilized the chi-square test and the two-sample t-test to compare categorical and quantitative variables, respectively, between individuals who reported past 30-day use of cannabis and those who did not. Whether or not an AA NDS used some form of cannabis was modeled utilizing logistic regression. Age, polytobacco use, and the PHQ-2 scale were fit into the model. Statistical significance was based on a type I error rate of 0.05. The data analysis for this paper was generated using SAS 9.4 (SAS Institute, Cary, NC).

Results

Out of the 262 participants analyzed, 99 (38%) of AA NDS reported some form of cannabis use in the past 30 days at baseline. Among these people who used cannabis, 43 (43%) used non-blunt cannabis, 23 (23%) used blunts as their only form of cannabis, and 33 (33%) used both blunts and cannabis users. People who used blunts reported 7.4 days of use in the past 30, while those who used non-blunt cannabis reported 5.6. Baseline characteristics of participants are displayed in Table 1.

Table 1.

Baseline characteristics of African American NDS by cannabis use

Overall (n=262) No past 30-day cannabis use (n=163) Past 30-day cannabis use (n=99) p-value
Demographic variables
  Age, mean (SD) 48.2 (11.6) 50.1 (10.9) 44.9 (12.1) <.001
  Male Sex, n (%) 131 (49.8) 78 (47.9) 52 (52.5) 0.46
  Cohabitation Status, n (%) married or living with a partner 61 (23.2) 31 (19.0) 30 (30.3) 0.04
  Employment Status, n (%) not currently employed 92 (35.0) 48 (29.5) 43 (43.4) 0.02
  Education Level, n (%) some college or higher 158 (60.1) 104 (63.8) 53 (53.5) 0.10
  Health Insurance that Pays for Most Medical Care, n (%) yes 203 (77.2) 130 (79.8) 72 (72.7) 0.19
  aPoverty level, n (%) ≤100 110 (47.2) 65 (44.8) 45 (51.7) 0.31
  Housing, n (%) own a home 29 (11.0) 18 (11.0) 11 (11.1) 0.99
  Perceived Health, n (%) very good/excellent 61 (23.2) 39 (23.9) 22 (22.2) 0.75
Psychosocial Variables
  Depressive symptoms (PHQ-2 ≥ 3), n (%) 58 (22.1) 25 (15.3) 32 (32.3) 0.001
  Alcohol misuse (AUDIT-C ≥ 3 for women and ≥ 4 for men), n (%) 130 (49.4) 73 (44.8) 57 (57.6) 0.04
  Prescription pain relievers, n (%) who used in the past 30 days 103 (39.2) 64 (39.3) 38 (38.4) 0.89
Smoking Variables
  Nondaily smoker type, n (%)
    Native (i.e., always been a nondaily smoker)
    Converted (i.e., formerly a daily smoker)
76 (28.9)
187 (71.1)
47 (28.8)
116 (71.2)
29 (29.3)
70 (70.7)
0.94
  Age when you started smoking cigarettes regularly, Mean (SD) 21.4 (8.8) 22.2 (9.2) 20.2 (8.1) 0.08
  Years of regular cigarette smoking, Mean (SD) 26.7 (13.3) 27.9 (12.6) 24.7 (14.2) 0.06
  Days smoked cigarettes in past 30 days, Mean (SD) 18.0 (6.2) 18.1 (6.4) 17.7 (5.9) 0.66
  Average cigarettes used on days smoked in past 30 days, Mean (SD) 4.5 (3.0) 4.7 (3.2) 4.4 (2.7) 0.43
  Use of polytobacco products in the past 30 days, n (%) yes 73 (27.9) 34 (20.9) 39 (39.4) 0.001
  Polytobacco products used in the past 30 days, Mean (SD) 2.6 (7.6) 1.9 (7.2) 3.7 (8.1) 0.06
  Nicotine Dependence, “How soon after waking do you first smoke,” n (%) within 30 mins 114 (43.5) 65 (39.9) 49 (49.5) 0.13
  Dependence Motives (WISDM Brief), Mean (SD) 32.7 (12.2) 32.5 (12.4) 32.9 (11.9) 0.82
  Number of 24 hour quit attempts in past year, Mean (SD) 5.5 (12.4) 6.0 (13.7) 4.7 (9.7) 0.38 b
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a

Data were missing for 30 (11%) participants regarding total yearly gross household income (11% of those who did not use cannabis in the past 30-days and 12% of those who used cannabis in the past 30-days).

b

Satterthwaite’s Approximation for unequal variances.

From the logistic regression model, cannabis use among AA NDS was associated with the use of polytobacco products (OR = 2.11, 95% CI [1.18–3.77], p = .012), depressive symptoms (OR = 1.22, 95% CI [1.05–1.42], p = .011), and younger age (OR = 0.97, 95% CI [0.94–0.99], p = .004). Sex and alcohol misuse were also explored but were not significantly associated with cannabis use.

Discussion

The high rates of cannabis use among AA NDS in this study (38%) exceed national rates of cannabis use among those who use tobacco (18%) (Schauer et al., 2015). Our findings highlighted various factors associated with the use of cannabis in this specific population, in addition to expanding the literature of nondaily smoking. While few studies have investigated the dual use of tobacco and cannabis alongside nondaily smoking, one study on young adult NDS found an association between the frequency of cannabis use and tobacco use (Doran et al., 2019). As the first analysis to look at factors associated with cannabis use among adult NDS, and more specifically, AA adult NDS, this paper begins to address the unique issues associated with people who use tobacco on a nondaily basis.

As hypothesized and reported previously (Cobb et al., 2018), polytobacco use was associated with cannabis and tobacco dual use. Cannabis and tobacco dual use, as well as polytobacco use, is associated with higher levels of nicotine dependence (Agrawal et al., 2012; Rubinstein et al., 2014; Sung et al., 2018) and may make quitting tobacco more difficult. We did not explore the association between cannabis and tobacco dual use and smoking cessation in the current study, but it is an important area for future work. Previous research has found compensatory effects between tobacco and cannabis that decrease the success of cessation attempts for either substance, in part due to substitution of cannabis during tobacco cessation and vice versa (Rabin and George, 2015; McClure et al., 2019).

Use of cannabis in our study was also correlated with depressive symptoms. Past findings show that dual use is associated with psychosocial problems including a variety of substance use and mental health disorders (Cohn et al., 2016). Moreover, there is a well-documented link between cigarette use and depression (Glassman et al., 1990) and a growing body of evidence supporting a similar association between cannabis use and depression (Lev-Ran et al., 2014).

Similar to previous findings (Montgomery, 2015; Schauer et al., 2015; Montgomery et al., 2019), we also found that tobacco and cannabis dual use was associated with younger age. This could be because younger people who smoke may be more open to experimenting with multiple products across substances. The relationship between age and dual use may also be closely related to initiation sequences of tobacco and cannabis. AAs are more likely than whites to use cannabis before tobacco (Kennedy et al., 2016), so future work may address tobacco use prevention among AAs who use cannabis.

Although past work suggests a possible association between male sex and cannabis and tobacco dual use (Corral et al., 2013; Schauer et al., 2015), this study, as well as a recent study in criminal justice populations (Montgomery et al., 2019), did not find a significant association. Likewise, despite studies demonstrating a correlation between heavy alcohol use and dual use of tobacco and cannabis (Schauer et al., 2015), alcohol misuse was not significantly related to dual use. Our lack of significance in these variables may be due to the small sample size that was not powered on these questions. In the future, we may need a larger sample to detect differences by sex or alcohol misuse status.

There are limitations in the current investigation that are of note. Our sample was treatment- seeking, and therefore limits the generalizability. Despite being the largest clinical cessation trial among AA NDS, our sample size was not powered to compare different types of cannabis use as participants were not recruited based on cannabis-use criteria. Blunt use was included in the TLFB, but non-blunt cannabis use and other forms of co-administration, including electronic delivery systems, were not included in the TLFB. Future work should assess differences between those who use blunts and other types of tobacco and cannabis co-administration products. Additionally, these data are from Kansas, where cannabis laws are among the strictest in the US. Previous research shows that dual use of cannabis and tobacco is higher in states that permit use of cannabis for medical purposes (Wang et al., 2016). In this regard, even higher rates of dual use may arise in states where cannabis use is legal or decriminalized.

Dual use of cannabis and tobacco poses harmful additive health effects that exceed the morbidity of either substance alone (Meier and Hatsukami, 2016). It may decrease the likelihood of smoking cessation by increasing nicotine dependence (Agrawal et al., 2012). Dual use is becoming increasingly important to investigate as legislation regarding use of cannabis for recreational and medical purposes continues to expand across the US. The results of our study support the need to continue tailoring treatments to vulnerable groups of people who use tobacco and cannabis users, especially as national disparities in use and health outcomes widen. As previously recommended, researchers and healthcare providers should assess both tobacco and cannabis use when individuals present with use of either substance (Montgomery, 2015). Diverse factors such as age, race/ethnicity, comorbidities, and patterns of tobacco use must be considered in order to address the social, behavioral, and cultural elements that interact with tobacco use and smoking-related health outcomes.

Acknowledgments

Financial Support

This work was supported by a Patient-Centered Outcomes Research Institute (PCORI) Award (AD-1310–08709) and by a CTSA grant from NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research # UL1TR000001. The statements in this publication are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee. Research reported in this publication was supported by the National Cancer Institute Cancer Center Support Grant P30 CA168524 and used the Biospecimen and Biostatistics and Informatics Shared Resources. Ahluwalia and Aston were supported in part by P20GM130414, a NIH funded Center of Biomedical Research Excellence (COBRE). Aston was supported by K01DA039311.

Footnotes

Conflicts of Interest

None declared.

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