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Published in final edited form as: Drug Alcohol Depend. 2020 Feb 19;209:107928. doi: 10.1016/j.drugalcdep.2020.107928

Current Cannabis Use and Smoking Cessation among Treatment Seeking Combustible Smokers

Andrew H Rogers 1, Justin M Shepherd 1, Julia D Buckner 2, Lorra Garey 1, Kara Manning 1, Michael F Orr 1, Norman B Schmidt 3, Michael J Zvolensky 1,4,5
PMCID: PMC8802811  NIHMSID: NIHMS1569821  PMID: 32092636

Abstract

Introduction:

Combustible tobacco smoking and cannabis use frequently occur together, and the use of both substances is associated with overall greater severity of tobacco and cannabis related problems. Observational work has found that cannabis use is associated with tobacco cessation failure, but research directly testing the longitudinal associations of cannabis use on tobacco cessation during smoking cessation treatment is lacking. The current study examined the impact of current cannabis use on combustible tobacco cessation outcomes.

Methods:

207 daily combustible tobacco smokers (Mage = 38.24 years, SD = 14.84, 48.1% male) were enrolled in a randomized controlled smoking cessation trial. Survival analyses and multi-level modeling were used to assess lapse and relapse behavior through 12-week follow up. The current study is a secondary data analysis.

Results:

Results of the current study suggest that cannabis use is associated with faster time to lapse (OR = .644, se = .188, p = .019), but not relapse (OR = −.218, se = .403, p = .525), compared to combustible tobacco-only smokers. Additionally, cannabis use was associated with lower likelihood of achieving any 7-day point prevalence abstinence during the 12 week follow up (b = 0.93, se =0 .24, p = 0.0001).

Conclusions:

The current study provides novel evidence that cannabis use may be related to combustible tobacco use in terms of faster time to lapse and lower likelihood of any 7-day point prevalence abstinence following smoking cessation treatment. Developing integrated cannabis-tobacco cessation treatments is an important next step in research focused on tobacco-cannabis use.

Keywords: Tobacco, Cannabis, Smoking Cessation, Combustible Cigarettes

1.0. INTRODUCTION

Cigarette use and cannabis use frequently co-occur (Schauer et al., 2015), with estimates suggesting that 5.2% of adults co-use cigarettes and cannabis, 69.% of cannabis users reported tobacco use, and 17.8% of cigarette users reported cannabis use. Additionally, daily cannabis smokers are more likely to be combustible tobacco users than non-daily cannabis smokers(Goodwin et al., 2018b). Additionally, compared to the general population, cannabis use is significantly more common among combustible tobacco smokers (Goodwin et al., 2018a), and a large percentage of cannabis use occurs among combustible tobacco smokers compared to non-combustible smokers (Pacek et al., in press). Further, cannabis use and cannabis use disorder are increasing among combustible tobacco smokers (Weinberger et al., 2018).

Individuals who use both tobacco and cannabis report more severe tobacco and cannabis related problems, including withdrawal and craving (Agrawal et al., 2009; Budney et al., 2008; Peters et al., 2012). Further, research across distinct research methodologies and populations has documented a reciprocal relation between combustible tobacco and cannabis use, such that they frequently co-occur and influence one another (Badiani et al., 2015; Kristman-Valente et al., 2017). For example, combustible tobacco use has been implicated in the onset and maintenance of cannabis use and cannabis use problems (Agrawal and Lynskey, 2009). Conversely, cannabis use has been related to the initiation and severity of combustible tobacco use (Patton et al., 2005). Additionally, compared to those that only smoke cannabis, those that smoke cannabis and tobacco are more likely to meet criteria for a cannabis use disorder and have more cannabis-related problems (Peters et al., 2012; Ream et al., 2008). Longitudinal epidemiological research indicates that combustible tobacco use is associated with increased odds of cannabis use and cannabis use being associated with increased odds of combustible tobacco smoking initiation (Badiani et al., 2015; Kristman-Valente et al., 2017).

Concurrent cannabis and tobacco use is related is associated with greater tobacco and cannabis withdrawal symptoms compared to using one substance (Vandrey et al., 2008). Moreover, observational studies have found that cannabis use is related to a decreased likelihood of a combustible tobacco use cessation attempt and an increased propensity for relapse during a quit attempt over time (Weinberger et al., 2018). Additionally, among combustible tobacco smokers, cannabis use compared to non-cannabis use was associated with greater likelihood of continued tobacco use (Ford et al., 2002).

Surprisingly, little research has examined the role of cannabis use during a combustible smoking cessation treatment, and existing research is inconclusive. For example, one study reported that among heavy alcohol drinkers enrolled in a smoking cessation study, cannabis use was not related to tobacco smoking lapse (Metrik et al., 2011). However, because the sample was comprised of individuals with alcohol use disorder, it is not clear if these findings generalize to non-alcohol use disorder samples of combustible smokers. This limitation is unfortunate, as understanding if cannabis use is related to combustible tobacco cessation outcomes during smoking cessation treatment would guide assessment and intervention programming for this vulnerable group (Lee et al., 2019). Theoretically, cannabis use may impact combustible tobacco cessation outcomes by a number of mechanisms, including negative reinforcement following mitigation of tobacco withdrawal symptoms (Baker et al., 2004), enhancement motives (e.g., tobacco smoking amplifying the effects of cannabis use)(Penetar et al., 2005), or drug substitution (e.g., individuals are substituting cannabis for tobacco, and ultimately returning to tobacco) (Fairbank et al., 1993; McClure et al., 2018b).

The purpose of the present investigation was therefore to examine the effect of current cannabis use on time to smoking lapse and relapse, as well as 7-day point-prevalent abstinence during 12 week follow up during a combustible tobacco cessation treatment among primary combustible tobacco users. It was hypothesized that current cannabis users would evince a faster time to lapse and to relapse to combustible tobacco use. Additionally, it was hypothesized that current cannabis use would be related to poorer combustible tobacco 7-day point-prevalence abstinence throughout the follow up period.

2.0. METHOD

2.1. Measures

Marijuana Smoking History Questionnaire (MSHQ)(Bonn-Miller and Zvolensky, 2009).

The MSHQ is a 21-item self-report measure of cannabis smoking history, including patterns of use (e.g. cannabis smoking rate, years of being a regular cannabis smoker). The MSHQ has been used successfully in prior work (Manning et al., 2018) and in the current study, the item, “Please rate your cannabis use in the past 30 days” was used to identify current cannabis users given the preliminary nature of this investigation. Specifically, those that indicated smoking any cannabis in the past 30 days at baseline were coded as 1 (current user), and those that reported not smoking cannabis in the past 30 days were coded as 0 (not current user).

Smoking History Questionnaire (SHQ)(Brown et al., 2002).

The SHQ is a self-report questionnaire used to assess smoking history and patterns of smoking (e.g. smoking rate, age of onset of initiation). It has been successfully used in previous studies as a measure of smoking history (Zvolensky et al., 2004). The present study used the following variables from the SHQ to characterize the sample: average number of combustible cigarettes smoked per day, age of onset of first cigarette, and number of years as a regular, daily combustible cigarette smoker.

Fagerström Test for Cigarette Dependence (FTCD; Fagerström, 2012).

The FTCD is a well-established 6-item scale designed to assess gradations in tobacco dependence. The measure exhibits a high degree of test-retest reliability (Pomerleau et al., 1994), and positive relations with key smoking variables (Heatherton et al., 1991; Payne et al., 1994). The FTCD was administered at baseline and was used as a covariate to account for variations in cigarette dependence.

Abstinence.

The Timeline Follow-Back (TLFB; Brown et al., 1998; Sobell and Sobell, 1992) procedure was used at all assessments to assess cigarette consumption at each day since the previous assessment. The assessment has demonstrated good reliability and validity with biochemical indices of smoking (Sobell and Sobell, 1992). Biochemical verification of smoking status at baseline was completed by carbon monoxide (CO) analysis of breath samples using a CMD/CO Carbon Monoxide Monitor (Model 3110; Spirometrics, Inc.). However, previous research suggests that concurrent cannabis use may increase expired CO (Hecht and Vogt, 1985), and thus, cigarette smoking lapse and relapse during the follow-up period were determined based on self-reported TLFB. Based on past research, it was assumed that the presence of a missing smoking status data indicated that a participant had smoked a cigarette when the closest available data point indicated that they had smoked; all others were coded as not smoking (Farris et al., 2016). To model lapse behavior, a dichotomous variable was created to indicate any smoking lapse that occurred during the first 28 days post quit day. Additionally, a variable was created to indicate the number of days that elapsed from quit day to 1) the first smoking lapse (slip), defined as smoking any amount following quit day (Piper et al., 2019; Shiffman et al., 1996), and 2) relapse, defined as a return to regular smoking following a period of abstinence, as defined in the current investigation as at least 5 cigarettes per day on three consecutive days (Piper et al., 2019; Shiffman et al., 1996). A dichotomous relapse variable was also created to model relapse behavior. Further, 7-day point prevalent abstinence was defined as complete abstinence (not even a puff) for 7-days prior to each assessment point (Piper et al., 2019).

2.2. Procedure

Data for the present study are a secondary data analysis from a multi-site randomized controlled clinical trial examining the efficacy of two smoking cessation interventions (Schmidt et al., 2016). Interested persons responding to community-based advertisements (e.g., flyers, newspaper ads, radio announcements) contacted the research team and were provided with a detailed description of the study via phone. Participants were then screened for initial eligibility, and if eligible, scheduled for a baseline appointment, where they provided written informed consent, completed a diagnostic interview, a computerized self-report assessment battery as well as biochemical CO verification of smoking status to evaluate eligibility criteria (CO > 8).

Inclusion criteria for the trial included: (1) 18–65 years of age; (2) being a daily smoker for at least 1 year; (3) currently smoking a minimum of 8 cigarettes per day; and (4) self-reported motivation to quit smoking (e.g., at least 5 on a 10-point scale). Exclusion criteria for the trial included: (1) current use of pharmacotherapy for smoking cessation (except the nicotine patch, which was provided by the study); (2) limited mental competency and inability to provide informed, voluntary, written consent; (3) endorsement of current or past psychotic-spectrum symptoms; (4) current suicidality or homicidal ideation; (5) history of significant medical condition; and (6) planning to relocate within the next 6 months.

Participants deemed eligible for the larger trial were randomly assigned to active or control treatment. The two treatment conditions included: a 4-session cognitive-behavioral smoking cessation program with an added anxiety sensitivity reduction component (active; i.e., Panic-Smoking Program), or a standard cognitive-behavioral smoking cessation program (control). Both treatments took place over four, 90-minute sessions occurring once per week. Both treatment groups received nicotine replacement therapy via the transdermal nicotine patch that was initiated at treatment Session 4 (quit day). Nicotine patch dosage followed guidelines established by the Food and Drug Administration (Zvolensky et al., 2017). Participants were offered the nicotine replacement therapy for up to 12 weeks post-quit. The study protocol was approved by the Institutional Review Boards at the University of Vermont and Florida State University (clinicaltrials.gov # NCT01753141).

2.3. Data Analytic Plan

Data were analyzed using SAS version 9.4. First, descriptive statistics and bi-variate relations were examined among variables. Additionally, group differences between cannabis users and non-cannabis users were examined for demographic and smoking variables. The present study examined the effect of current cannabis use (at baseline) on time to smoking lapse and relapse during the first 28 days post-quit, and the effect of current cannabis use on any 7-day point-prevalent abstinence throughout 12 weeks. These timelines were selected to increase the odds of individuals remaining abstinent from tobacco (Farris et al., 2016; Piper et al., 2009). For all models, covariates included age, gender, baseline FTCD, and treatment condition.

To predict lapse and relapse, two multivariate Cox proportional hazards regression analyses were used to examine the predictive value of current cannabis use on time to lapse and relapse. All models included two steps, with covariates entered into the first step and current cannabis use entered into the second step.

Seven-day point-prevalent abstinence through the 12 week follow up was modeled using multi-level modeling (MLM), in accordance with guidelines put forth by the Society for Nicotine and Tobacco Research (Hall et al., 2001), which allows for all subjects to be included, regardless of missing data. First, an unconditional model, without covariates was run, followed by a conditional model including theoretically relevant covariates. Assessments from quit week, week one, week two, week four, and week twelve were included as outcome variables. To model point-prevalence abstinence throughout the 12 week follow up, multivariate MLM (MMLM) was used to avoid Type 1 error inflation and can include any assessment from which any outcome data was obtained. To account for the dichotomous structure of the outcome variable, we used generalized MMLM with a logistic linking function and robust standard errors. Random intercepts were modeled.

3.0. RESULTS

3.1. Participants

Participants (N=207, Mage = 38.24 years, SD = 14.84, 48.1% male) were treatment-seeking daily combustible tobacco smokers enrolled in a clinical trial evaluating the efficacy of a smoking cessation treatment targeting anxiety sensitivity compared to a standard smoking cessation treatment (Schmidt et al., 2016; Zvolensky et al., 2018).

In terms of demographic characteristics, 85.6% identified as White, 7.4% as Black non-Hispanic, 0.3% as Black Hispanic, 3.7% as White Hispanic, 0.7% as Asian, and 2.3% as other. In terms of education, 2.4% reported not having graduated from high school, 16.4% reported graduating from high school, 35.3% attended some college, and the remaining participants (45.9%) graduated from college (2-year, 4 year, or graduate/professional school). Additionally, 37.7% reported being married or living with a partner, 2.4% reported being widowed, 18.9% reported being separated or divorced, and 41.1% reported being never married. Participants who used cannabis reported first smoking cannabis at 16.26 (SD = 3.42) years old, reported daily cannabis use at age 16.90 (SD = 7.46), and reported being a daily cannabis user for 6.42 (SD = 8.54) years. See table 1 for demographic and smoking characteristics by group.

Table 1.

Sample Descriptive Information

Tobacco Only (n=125) Tobacco-Cannabis Co-Use (n=82)
Age 34.41 (SD = 8.94) years 25.86 (SD = 8.73) years
Gender 50.0% female 50.8% female
Age of first cigarette 14.39 (3.45) 14.93 (3.05)
Daily smoking age 17.52 (3.74) 17.36 (2.71)
Years as a daily smoker 16.20 (8.80) 8.15 (8.31)
Average CPD 14.66 (7.26) 13.20 (6.94)
FTCD Total 4.86 (2.20) 4.12 (2.14)
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Note: Demographic and smoking characteristics between tobacco-only users and tobacco-cannabis co-users.

3.2. Attrition Analyses

A total of 603 people signed the consent form an entered the study. Compared to those who remained in the study and completed treatment and follow up sessions, participants who dropped out of the study were significantly younger in age (t(623) = −2.55, p = 0.01), and were significantly younger when they started regular daily smoking (t(608) = −2.16, p = 0.03). There were no significant differences on other cigarette and cannabis variables, including average cigarettes per day, number of years as a daily smoker, age of first using cannabis and age of daily cannabis use (p’s > 0.05).

3.3. Bi-Variate Correlations and Group Comparisons

Current cannabis use was significantly negatively correlated with age, years as a daily smoker, and cigarette dependence, indicating that current cannabis use was associated with lower levels of these variables (see Table 2)

Table 2.

Bi-variate correlations among variable

1. 2. 3. 4. 5. 6. 7. 8.
1. Age 1
2. Gender 0.054 1
3. Age of first cigarette −0.017 −.168* 1
4. Age of regular daily smoking 0.126 −0.056 .443** 1
5. Years as regular daily smoker .916** 0.082 −.159* −.200** 1
6. Average cigarettes (as regular daily smoker) .455** −0.024 0.020 −0.068 .468** 1
7. Average cigarettes (last week) .339** −0.111 −0.017 −0.052 .338** .677** 1
8. Cigarette Dependence .419** 0.010 −0.076 −0.074 .448** .635** .627** 1
9. Current cannabis use −.382** −0.107 0.086 −0.047 −.345** −0.094 −0.061 −.131*
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*

p<0.05;

**

p<0.01.

Bi-variate relations among variables used in the current study.

3.4. Survival Analyses

Time to lapse.

Examining step 1 of the model indicated that there was no significant improvement from the baseline model (χ2(4) = 4.90, p = .30). Age was a significant predictor of smoking lapse (OR = .989, se = .007, p = .046), such that decreased age was associated with quicker smoking lapse. For step 2 of the model, there was a significant increase in model fit (Δ χ2(1) = 5.43, p = .02). Current cannabis use was significantly associated with faster smoking lapse (OR = .644, se = .188, p = .019; see Figure 1).

Figure 1. Surival Function for Smoking Lapse.

Figure 1.

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N=207, Mage = 38.24 years, SD = 14.84, 48.1% male. The effect of current cannabis use on days to smoking lapse. Thin line is those that do not use cannabis, and thick line is those that use both cannabis and combustible tobacco.

Time to relapse.

There were no significant effects at step 1 or step 2 (OR = −.218, se = .403, p = .525).

3.5. 7-day Point Prevalence Abstinence

Unconditional Model.

Random intercept covariance was significant indicating significant variability in baseline (intercept) levels of cannabis use influencing the level of the outcome, and variability between participants in the intercept (b = 1.51, se = 0.35, p = <.001). Examining fixed effect parameters indicated that current cannabis use was significantly associated with point-prevalent abstinence (b = 0.91, se =0 .21, p < 0.0001), such that current cannabis users were less likely to be abstinent from combustible tobacco throughout the follow up.

Conditional Model.

Examining random intercept covariance indicated significant intercept covariance (b = 1.64, se = .38, p = <.001). Examining the fixed effect parameter estimates suggested that baseline cigarette dependence (b = −0.14, se =0 .05, p = 0.001) as well as current cannabis use was significantly associated with 7-day point-prevalent abstinence (b = 0.93, se =0 .24, p = 0.0001); specially current cannabis users were significantly more likely to be non-abstinent from cigarettes through week 12.

4.0. DISCUSSION

The current study examined current cannabis use on a combustible tobacco cessation attempt (time to lapse, relapse, and point prevalence abstinence) among treatment seeking combustible tobacco smokers enrolled in a clinical trial for smoking cessation. Results from the current study rejected the null hypotheses, such that current cannabis use was associated with faster time to lapse and supported the null hypothesis that cannabis use was not associated with time to relapse. Current cannabis use also was inversely related to point prevalence abstinence at 12 weeks post quit attempt. Importantly, these effects were evident over the variance accounted for by age, gender, treatment condition, and baseline severity of cigarette dependence. Further, these results sit in the larger context that the cannabis users in the present sample demonstrated fewer years of being a regular combustible cigarette smoker and less cigarette dependence (FTCD total score). Thus, despite the cannabis-tobacco sample being ‘less severe’ on these tobacco-related variables, they demonstrated less success in terms of lapse and point prevalence abstinence. These findings are in line with previous research suggesting that cannabis use may impact combustible tobacco cessation over time in a longitudinal observation study (Weinberger et al., 2018), and extends past work to implicate cannabis use in smoking cessation failure among individuals making an active quit attempt during treatment.

Current cannabis use was not associated with smoking relapse following quit day. Although this finding was unexpected, there are several plausible hypotheses that may help explain these results. For instance, extant work suggests that early smoking lapse is often considered to be the most clinically significant predictor of returning to pre-quit levels of smoking (Bolman et al., 2018; Brandon et al., 1990; Brown et al., 2005; Roche et al., 2014). However, it is possible that a full relapse was not detected in the time period assessed, as has been found in past research (Zvolensky et al., 2009). Additionally, given the fact that all participants received treatment for smoking cessation, it is possible that following a smoking lapse, they were able to implement coping strategies taught during treatment strategies to prevent a relapse.

The results from the current study may have important clinical implications. Given that current cannabis use is related to several combustible smoking cessation variables, it may be important for providers to assess and target cannabis use prior to initiating a combustible tobacco cessation attempt. Yet, given the fact that tobacco use may be contributing to and driving difficulties quitting cannabis (McClure et al., 2018a), there may be more clinical utility in targeting both substances at the same time. Research examining tobacco-alcohol relations found clinical utility in concurrently targeting both substances (Prochaska et al., 2004), and thus, using this type of model for cannabis-tobacco relations may be warranted. Some previous work among individuals attempting to quit cannabis found that targeting both cannabis and tobacco use improved cannabis use outcomes, and to a lesser extent, tobacco use outcomes (Lee et al., 2014). These treatments integrate evidenced based motivational enhancement therapy, cognitive behavior therapy, and contingency management. Therefore, there may be merit in developing integrated cessation interventions that target both cannabis and combustible tobacco use. Yet, because the results from the current study suggests that cannabis use was associated with only faster time to lapse, there may need to be psychoeducation about the complexities in involved. Namely, cannabis may be associated with lapse but not relapse. To more firmly established clinical implications of cannabis-tobacco relations for intervention programming, replication and extension to other samples is first warranted.

The current study has several limitations. First, current cannabis use was coded dichotomously to determine the broadband effect of cannabis use on combustible cigarette cessation outcomes. It is possible that different levels of cannabis use may impact lapse and point-prevalence abstinence. Therefore, future work should extend these findings by examining frequency and quantity of cannabis use, as well as the perceived intoxication and/or chemical potency of cannabis, to better understand its relation to cessation outcomes for users of both cannabis and tobacco. Second, the sample was predominately White and generally well-educated. Future work may benefit from replicating these findings among a more racially and ethnically diverse sample. Third, we did not model the use of electronic cigarette use in the current sample. There is therefore a need to document the prevalence and impact of electronic cigarette use among users of both combustible cigarettes and cannabis. Fourth, information regarding past illicit substance use, including opioids, benzodiazepines, and stimulants was not collected, and it is possible that a history of substance use may impact lapse and relapse behavior. Finally, given the observed association between cannabis use and smoking cessation outcomes, there is a need for future research to explicate the mechanisms underlying the observed associations. There may be utility in exploring intra-individual difference factors, including self-efficacy for remaining abstinent (Stephens et al., 1995), false safety behavior(Buckner et al., 2019), emotion dysregulation (Rogers et al., 2019), among others, in future research on tobacco-cannabis use.

Overall, the present investigation provides novel empirical evidence that current cannabis users compared to non-cannabis users may experience poorer combustible cigarette cessation outcomes, including time to lapse and lower likelihood of any 7-day point-prevalence abstinence during 12-weeks post quit attempt during smoking cessation treatment. Future work should seek to better understand factors that play a role in greater lapse rates among cannabis users to determine whether smoking lapse occurs as a result of cannabis intoxication or whether other biopsychosocial factors.

Highlights.

  • Cannabis smoking at baseline is prospectively related to cigarette smoking outcomes

  • Cannabis use at baseline is associated with quicker time to smoking lapse

  • Cannabis use at baseline is associated with lower likelihood of point-prevalent smoking abstinence

Acknowledgments

Author Disclosures:

Role of funding source:

This study was funded by a National Institute of Mental Health (R01-MH076629) grant to MJZ and NBS. The funding source had no involvement in the conduct of the research and/or preparation of the article.

Footnotes

Declaration of Interests

The authors declare there are no conflicts of interest

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