Purpose of review

This article aims to summarize current research on digital health for assessment and intervention targeting tobacco and cannabis co-use and to answer the following questions: Which digital tools have been used? Which populations have been targeted? And what are implications for future research?

Recent findings

Ecological Momentary Assessment (EMA) via text messages or interactive voice response calls has been used to capture co-use patterns within a time window or co-administration of both substances via blunts among young adults. Feasibility of multicomponent interventions targeting dual cessation of both substances among adult co-users with cannabis use disorder, delivered via smartphone apps, online, and computer modules has been demonstrated.

Summary

Digital tools, particularly those using EMAs and mobile sensors, should be expanded to assess co-use of emerging tobacco and cannabis products. Digital cessation interventions should be tailored to different groups of co-users and address specific mechanisms underlying different co-use patterns.

Purpose

The aim of the article was to examine flavors of alternative tobacco products most commonly used by young adults (YAs).

Methods

California YA (N = 365; mean age = 20.0 years) were surveyed in 2018 about the first and usual flavors of alternative tobacco products used. Flavor categories were fruit, candy, menthol, mint, coffee, spice, alcohol, wintergreen, and tobacco.

Results

Fruit and mint were the most common flavors used (pod-based e-cigarettes: 35.4% and 29.3%; other e-cigarettes: 52.7% and 23.1%; hookah: 45.4% and 18.5%; cigars/cigarillos: 22.4% and 6.9%, respectively). For other e-cigarettes and hookah, candy was also popular (20.5% and 14.8%, respectively). For pod-based and other e-cigarettes, menthol was widely used (13.4% and 17.0%, respectively). Approximately half of the ever-flavor users reported they "usually" used the same flavors across products (menthol users: 52.2%; fruit users: 51.7%; mint users: 44.0%; and candy users: 43.8%).

Conclusions

YA are clearly using flavors, specifically fruit, mint, candy, and menthol, in their tobacco products.

Purpose

The aim of the article was to examine flavors of alternative tobacco products most commonly used by young adults (YAs).

Methods

California YA (N = 365; mean age = 20.0 years) were surveyed in 2018 about the first and usual flavors of alternative tobacco products used. Flavor categories were fruit, candy, menthol, mint, coffee, spice, alcohol, wintergreen, and tobacco.

Results

Fruit and mint were the most common flavors used (pod-based e-cigarettes: 35.4% and 29.3%; other e-cigarettes: 52.7% and 23.1%; hookah: 45.4% and 18.5%; cigars/cigarillos: 22.4% and 6.9%, respectively). For other e-cigarettes and hookah, candy was also popular (20.5% and 14.8%, respectively). For pod-based and other e-cigarettes, menthol was widely used (13.4% and 17.0%, respectively). Approximately half of the ever-flavor users reported they "usually" used the same flavors across products (menthol users: 52.2%; fruit users: 51.7%; mint users: 44.0%; and candy users: 43.8%).

Conclusions

YA are clearly using flavors, specifically fruit, mint, candy, and menthol, in their tobacco products.

Background

There are no clinical practice guidelines addressing the treatment of tobacco-cannabis co-use and a dearth of studies to inform treatment for co-use. This narrative review aims to (1) summarize promising intervention components used in published co-use treatment studies, (2) describe key gaps and emerging issues in co-use, and (3) provide recommendations and considerations in the development and evaluation of co-use interventions.

Methods

We conducted a literature search in June 2024 across several databases to update previous reviews on tobacco-cannabis co-use treatment. We found 9 published intervention studies that specifically addressed treatment for both substances. Data from these studies were manually extracted and summarized.

Results

Most of the 9 included studies (1) focused on acceptability and/or feasibility, (2) provided both psychosocial/behavioral and pharmacotherapy intervention components, (3) were conducted in adults, and (4) were delivered in-person, with some having digital asynchronous components, for a 5-to-12-week duration. The most common psychosocial/behavioral strategies used were Cognitive Behavioral Therapy, Motivational Interviewing, and Contingency Management; while the most common pharmacotherapy was Nicotine Replacement Therapy. There was no evidence of compensatory use of tobacco or cannabis when providing simultaneous treatment for both substances.

Conclusions

The literature to date provides support for well-integrated multi-component interventions of psychosocial/behavioral and pharmacotherapy strategies for co-use treatment. This review reinforces an urgent need for treatments targeting tobacco and cannabis co-use. Future interventions should address key gaps, including co-use of vaporized products among youth and young adults, tailored interventions for priority populations, and digital applications to increase reach and advance health equity.

BACKGROUND: E-cigarettes are promoted as less harmful than cigarettes. There has not been a direct comparison of health effects of e-cigarettes or dual use (concurrently using e-cigarettes and cigarettes) with those of cigarettes in the general population. METHODS: Studies in PubMed, EMBASE, Web of Science, and PsychINFO published through October 1, 2023, were pooled in a random-effects meta-analysis if five or more studies were identified with a disease outcome. We assessed risk of bias with Risk Of Bias In Non-randomized Studies of Exposure and certainty with Grading of Recommendations, Assessment, Development, and Evaluations. Outcomes with fewer studies were summarized but not pooled. RESULTS: We identified 124 odds ratios (94 cross-sectional and 30 longitudinal) from 107 studies. Pooled odds ratios for current e-cigarette versus cigarette use were not different for cardiovascular disease (odds ratio, 0.81; 95% confidence interval, 0.58 to 1.14), stroke (0.73; 0.47 to 1.13), or metabolic dysfunction (0.99; 0.91 to 1.09) but were lower for asthma (0.84; 0.74 to 0.95), chronic obstructive pulmonary disease (0.53; 0.38 to 0.74), and oral disease (0.87; 0.76 to 1.00). Pooled odds ratios for dual use versus cigarettes were increased for all outcomes (range, 1.20 to 1.41). Pooled odds ratios for e-cigarettes and dual use compared with nonuse of either product were increased (e-cigarette range, 1.24 to 1.47; dual use, 1.49 to 3.29). All included studies were assessed as having a low risk of bias. Results were generally not sensitive to study characteristics. Limited studies of other outcomes suggest that e-cigarette use is associated with additional diseases. CONCLUSIONS: There is a need to reassess the assumption that e-cigarette use provides substantial harm reduction across all cigarette-caused diseases, particularly accounting for dual use.

Background

Co-use of tobacco and cannabis is highly prevalent among young US adults. Same-day co-use of tobacco and cannabis (ie, use of both substances on the same day) may increase the extent of use and negative health consequences among young adults. However, much remains unknown about same-day co-use of tobacco and cannabis, in part due to challenges in measuring this complex behavior. Nuanced understanding of tobacco and cannabis co-use in terms of specific products and intensity (ie, quantity of tobacco and cannabis use within a day) is critical to inform prevention and intervention efforts.

Objective

We used a daily-diary data collection method via smartphone to capture occurrence of tobacco and cannabis co-use within a day. We examined (1) whether the same route of administration would facilitate co-use of 2 substances on the same day and (2) whether participants would use more tobacco on a day when they use more cannabis.

Methods

This smartphone-based study collected 2891 daily assessments from 147 cigarette smokers (aged 18-26 years, n=76, 51.7% female) during 30 consecutive days. Daily assessments measured type (ie, cigarette, cigarillo, or e-cigarette) and intensity (ie, number of cigarettes or cigarillos smoked or number of times vaping e-cigarettes per day) of tobacco use and type (ie, combustible, vaporized, or edible) and intensity (ie, number of times used per day) of cannabis use. We estimated multilevel models to examine day-level associations between types of cannabis use and each type of tobacco use, as well as day-level associations between intensities of using cannabis and tobacco. All models controlled for demographic covariates, day-level alcohol use, and time effects (ie, study day and weekend vs weekday).

Results

Same-day co-use was reported in 989 of the total 2891 daily assessments (34.2%). Co-use of cigarettes and combustible cannabis (885 of the 2891 daily assessments; 30.6%) was most commonly reported. Participants had higher odds of using cigarettes (adjusted odds ratio [AOR] 1.92, 95% CI 1.31-2.81) and cigarillos (AOR 244.29, 95% CI 35.51-1680.62) on days when they used combustible cannabis. Notably, participants had higher odds of using e-cigarettes on days when they used vaporized cannabis (AOR 23.21, 95% CI 8.66-62.24). Participants reported a greater intensity of using cigarettes (AOR 1.35, 95% CI 1.23-1.48), cigarillos (AOR 2.04, 95% CI 1.70-2.46), and e-cigarettes (AOR 1.48, 95% CI 1.16-1.88) on days when they used more cannabis.

Conclusions

Types and intensities of tobacco and cannabis use within a day among young adult smokers were positively correlated, including co-use of vaporized products. Prevention and intervention efforts should address co-use and pay attention to all forms of use and timeframes of co-use (eg, within a day or at the same time), including co-use of e-cigarettes and vaporized cannabis, to reduce negative health outcomes.

Given the emerging tobacco landscape, dual use of cigarettes and e-cigarettes has increased among young adults, but little is known about its associated factors. Peer crowds, defined as macro-level connections between individuals with similar core values (e.g., "Hip Hop" describing a group that prefers hip hop music and values strength, honor, and respect), are a promising way to understand tobacco use patterns. We examined associations between peer crowds and tobacco use patterns by using data from a cross sectional survey of 1340 young adults in the San Francisco Bay Area in 2014. Outcomes were the past 30-day use of: neither cigarettes nor e-cigarettes; cigarettes but not e-cigarettes; e-cigarettes but not cigarettes; and both cigarettes and e-cigarettes. Peer crowds included Hipster, Hip Hop, Country, Partier, Homebody, and Young Professional. Multinomial regression analysis indicated that peer crowds were significantly associated with different tobacco use patterns. Compared to Young Professionals, Hip Hop and Hipster crowds were more likely to dual use; Hipsters were more likely to use e-cigarettes only, and Country participants were more likely to smoke cigarettes only. These findings suggest that tobacco control campaigns and cessation interventions should be tailored to different young adult peer crowds and address poly-tobacco use.

Cannabis vaping may increase susceptibility to COVID-19 infection and related outcomes; however, little is known about the impact of the pandemic on cannabis vaping among US young populations. This study examined self-reported changes in cannabis vaping since the pandemic and factors associated with changes. A national, cross-sectional survey was conducted among 4,351 US adolescents and young adults (13-24 years old) in May 2020. Of those, 1,553 participants who reported ever vaping cannabis were included in the analytic sample. Binary outcome was self-reported increase in cannabis vaping (more hours/times of vaping in a day) vs. no change/quitting/reducing/switching. Weighted logistic regression examined associations between independent variables (i.e., risk perceptions of vaping, cannabis dependence, and stress/anxiety) and the outcome, controlling for sociodemographic factors. Overall, 6.8% reported increasing cannabis vaping since the pandemic, 37.0% quitting or reducing vaping in general, and 42.3% no change. Participants were more likely to report increased cannabis vaping if they perceived "Vaping is safer than smoking cigarettes" (Adjusted Odds Ratio [AOR] = 3.66; 95%CI = 1.43-9.38), reported more dependence on cannabis vaping (AOR = 1.59; 95%CI = 1.11-2.27), and were female (AOR = 2.80; 95%CI = 1.23-6.36). Those perceiving "Vaping cannabis can cause lung injuries" were less likely to increase cannabis vaping (AOR = 0.37; 95%CI = 0.18-0.76). Findings indicate that adolescent and young adult ever-cannabis vapers were more likely to report decreasing vaping generally than increasing cannabis vaping and most did not change use during the early pandemic. Educational campaigns should address potential health risks of cannabis vaping and focus on lung health to reduce use among young people during and following the pandemic.

Introduction

Cannabis use patterns among adolescents and young adults (AYAs) have changed recently, with increasing use of non-combustible cannabis products. Little is known about perceived risks or benefits related to non-combustible products (e.g., vaporized and edible cannabis). We examined whether AYAs' perceived risks and benefits differ across four cannabis products, and by use status.

Methods

We conducted a survey of 433 California AYAs (M_age = 18.9 years old, 66.5% females) during 2017-2018. We compared a variety of perceived risks and benefits corresponding to short-term and long-term use of each product (combustible, blunt, vaporized, and edible cannabis), and between ever and never users.

Results

Participants perceived combustible cannabis and blunts conferred the greatest risk for short-term (bad cough, trouble catching breath) and long-term (lung disease, oral and lung cancer, and heart attack) health outcomes and short-term social risks (friends upset, getting into trouble). These products were also perceived to have greater short-term and long-term benefits (i.e., reducing mental health problems) than vaporized and edible cannabis. The most common perceived risks were "get into trouble" and "become addicted." The most common benefits were "feel high or buzzed" and "feel less anxious." Ever cannabis users perceived less risks and greater benefits related to cannabis use than never users.

Conclusions

AYAs differentially perceived risks and benefits related to use of four cannabis products. Public health and education efforts should address both perceived and real risks and benefits of specific cannabis products to prevent cannabis use among AYAs.

Background and objectives

Little is known about whether people in substance use disorder (SUD) treatment are at risk for multiple-tobacco use. We examined the factors associated with dual- and polytobacco use among clients in SUD treatment.

Methods

A cross-sectional survey was conducted in 2019 among 562 clients (M_age  = 39, 74% male) in 20 residential SUD treatment programs in California, USA. The outcomes included single-, dual- (use of two products), and polytobacco use (use of three of more products). Independent variables were nicotine dependence, quitting-related factors, blunt/spliff use, and health-related factors. A multinomial model examined associations between the independent variables and the outcome, controlling for demographics, and time in treatment.

Results

Overall, 32.6%, 18.9%, and 14.0% of the sample were single-, dual-, and polytobacco users, respectively. Factors associated with increased odds of polytobacco use included greater nicotine dependence (adjusted odds ratio [AOR] = 1.60; 95% CI = 1.19, 2.16), ever using e-cigarettes for quitting (AOR = 4.56; 95% CI = 2.23, 9.34), and past 30-day use of blunt/spliff (AOR = 2.96; 95% CI = 1.48, 5.89). Factors associated with increased odds of dual use were ever using e-cigarettes for quitting (AOR = 3.19; 95% CI = 1.79, 5.66) and reporting more mentally unhealthy days (AOR = 1.05; 95% CI = 1.02, 1.07).

Conclusion and scientific significance

This study extends the literature on tobacco use among people in SUD treatment by revealing the high prevalence of dual- and polytobacco use and the unique characteristics of users. The findings have implications for interventions reducing all types of tobacco use in this understudied population.