https://orcid.org/0000-0002-3532-9581
Abstract
Background
An increasing number of states are legalizing the medicinal and/or recreational use of marijuana. Adult perceptions of harm have decreased and marijuana use has increased. This is in contrast to declining cigarette smoking. In this article we examine independent use and dual use of marijuana and tobacco products.
Methods
Data are from the 2018 Minnesota Adult Tobacco Survey (N = 6055). Estimates were calibrated on sex, race, location, and education from the American Community Survey.
Results
In 2018, 15.4% of adults smoked cigarettes in the past 30 days, 7.6% used marijuana and 6.0%, 3.0%, and 1.1% used e-cigarettes, cigars, and waterpipe, respectively. Use of marijuana and cigarettes was 3.3% and use of marijuana and e-cigarettes was 2.2%. Among past 30-day marijuana users, 89.7% smoked it as a joint, blunt, or in waterpipes, 22.1% vaped it in an e-cigarette or a vaping device. Across multinomial regression models, marijuana use and dual use with tobacco products was more likely among males, younger age groups, and African Americans.
Conclusions
As policies to expand the sale and use of marijuana are considered, states should anticipate the need to monitor trends and to plan surveys of sufficient sample size with specific questions on marijuana use. Understanding the proportion of the population that uses both marijuana and tobacco has implications for prevention and treatment of both substances.
Introduction
In 1996, California became the first state to pass a medical marijuana law. By the end of 2020, 36 other United States states had passed a similar law and 15 United States states had legalized small amounts of marijuana for adult recreational use (National Conference of State Legislatures (NCSL), Citation2021). These state laws reflect a significant shift in public perceptions of marijuana use as a risky behavior (Azofeifa et al., Citation2016; Carliner et al., Citation2017). Currently, two-thirds of US adults think marijuana use should be legal, reflecting a growing trend since 2000 (McCarthy, Citation2018). In concert with changing state laws and shifting society perceptions, current use of marijuana has increased among US adults (Azofeifa et al., Citation2016; Mauro et al., Citation2019; McCarthy, Citation2018). Between 2002 and 2014 there were significant increases in past year, past month and daily marijuana use across multiple demographic groups, with notable increased use reported by adults ages 55 and older (Azofeifa et al., Citation2016).
In contrast to the trends of increased marijuana use and changes in attitudes, overall cigarette smoking prevalence has been decreasing. National adult cigarette smoking prevalence dropped from 20.9% in 2005 to 13.7% in 2018 (Centers for Disease Control and Prevention (CDC), Citation2019). Tobacco and marijuana share some common attributes: combusted smoking is the most common method of use, and both share similar user demographics, for example, use is more common among adults with lower incomes and lower levels of education (National Academies of Sciences et al., Citation2017). Both tobacco and marijuana also share a changing marketplace with many new products introduced in recent years, including electronic devices to vaporize nicotine or marijuana. In addition, there are several ways marijuana and tobacco are used simultaneously (Lemyre et al., Citation2019). For example, some users add tobacco to marijuana cigarettes (Banbury et al., Citation2013), or marijuana can be smoked in cigarette rolling papers or in an emptied cigar (McDonald et al., Citation2016). In addition, marijuana users have also reported switching to tobacco as a substitute for marijuana (Banbury et al., Citation2013).
All forms of combusted tobacco and marijuana used together represent a higher likelihood of increased health risks (Meier & Hatsukami, Citation2016; Peters et al., Citation2014), lower odds of making a tobacco quit attempt (Strong et al., Citation2018), and increased tobacco use and dependence (Akbar et al., Citation2019; McClure et al., Citation2014).
As more states legalize the recreational use of marijuana the need for state-level monitoring will be important. To that end, we present an initial assessment of marijuana use and dual use with tobacco in Minnesota, a state with an existing medicinal marijuana program that is debating a change in state law to legalize adult recreational marijuana use.
Methods
Data source
Data were collected as part of the 2018 Minnesota Adult Tobacco Survey (MATS), which uses computer-assisted telephone interviewing and a random digit dialing (RDD) methodology to obtain a statewide sample of civilian, non-institutionalized adults ages 18 years or older (n = 6055). Methodological detail regarding sampling and weighting is available at http://www.clearwaymn.org/MATS. The Minnesota Department of Health Institutional Review Board approved the study.
Measures
Demographic factors included age, gender, race/ethnicity, income, and highest educational level completed. Self-reported age was categorized into 18–24, 25–44, 45–64, and 65 or older. Minnesotans were categorized into the following categories: Non-Hispanic White, non-Hispanic Black/African American, non-Hispanic other races and Hispanic. Education was categorized as less than high school, high school graduate or GED, some college, and college degree or more. Income categories included $35,000, $35,001 to $50,000, $50,001 to $75,000, and more than $75,000.
Respondents reported their past 30-day use of tobacco and marijuana. Users of cigarettes, e-cigarettes, waterpipe, and marijuana were defined as those who used the product at least once in the past 30 days. Cigar users (including cigarillos, little filtered cigars) had used these tobacco products at least 20 times in their lifetime and had used the product at least once in the past 30 days. Marijuana users were asked about blunt use in the past 30-days: “sometimes people take tobacco out of a traditional cigar, cigarillo or filtered cigar and replace it with marijuana, or marijuana mixed with tobacco. This is often called a blunt or a spliff. During the past 30 days, when you smoked marijuana, did you smoke it as a blunt or a spliff?” Additionally, marijuana users were asked about modes of marijuana use, (1) if they smoked it in a joint, blunt or waterpipe, (2) if they vaped it, (3) if they ate it in food such as in a cookie, candy, mint or cracker, or (4) if they used it in some other way. Participants who reported cigarette use and no other tobacco product or marijuana were categorized as exclusive cigarette smokers. Similarly, those who reported e-cigarette only use (no other tobacco or marijuana) and cigar use (no other tobacco or marijuana) were defined as exclusive e-cigarettes and exclusive cigar users, respectively. Respondents who only used marijuana and no tobacco product were categorized as exclusive marijuana users. Marijuana users who also smoked cigarettes in the past 30 days were categorized as marijuana and cigarette dual users. Similarly, past 30-day users of marijuana and e-cigarettes were categorized as dual users of marijuana and e-cigarettes and past 30-day users of marijuana and cigar were categorized as dual users of marijuana and cigars. Furthermore, to understand exclusive and dual use, four-level mutually exclusive groups were considered based on self-reported tobacco (cigarettes, e-cigarettes, cigars) and marijuana use separately: (1) no past 30-day use, (2) exclusive cigarette/e-cigarette/cigar past 30-day use, (3) exclusive past 30-day marijuana use, (4) past 30-day marijuana and cigarette/e-cigarette/cigar dual use.
Analytic plan
All analyses were conducted using Stata/SE version 15.1 software using SVY procedures to account for complex study design. Weighted prevalence rates of past 30-day cigarette, cigar, waterpipe, e-cigarette and marijuana by demographic variables were estimated, along with dual use of marijuana as described above (). Mode of marijuana use by demographics was assessed among past 30-day marijuana users (). Three separate multivariate multinomial logistic regression models were fit to predict (1) past 30-day exclusive cigarette use, past 30-day exclusive marijuana use, dual past 30-day use of cigarettes and marijuana compared to no past 30-day use; (2) past 30-day exclusive e-cigarette use, past 30-day exclusive marijuana use, dual past 30-day use of e-cigarettes and marijuana compared to no past 30-day use; and (3) past 30-day exclusive cigar use, past 30-day exclusive marijuana use, dual past 30-day use of cigars and marijuana compared to no past 30-day use ().
Table 1. Past 30-day use of marijuana and tobacco among Minnesota adults, 2018.
Table 2. Modes of marijuana use among past 30-day users by selected demographics.
Table 3. Multivariate regression estimates of cigarette, e-cigarette, cigar, marijuana and dual use among Minnesota Adults, 2018..
Results
Among Minnesota adults in 2018, the highest tobacco use prevalence was past 30-day cigarette smoking (15.4%), followed by e-cigarette use (6.0%) (). Past 30-day marijuana use was 7.6%, with an inverse gradient of prevalence by age. Overall, past 30-day dual use of marijuana and cigarettes was 3.3%, and marijuana and e-cigarettes by 2.2%. Higher use of e-cigarettes, marijuana, and dual use of e-cigarettes and marijuana was found among young adults compared to other age groups and among males compared to females (). Similarly, Minnesotans with less than high school education had higher prevalence of past 30-day cigarette, cigar, marijuana, dual use of e-cigarettes and marijuana, and dual use of cigarettes and marijuana than those with more completed education.
The modes of marijuana use are reported in , and 89.7% “smoked in a joint, blunt or waterpipe,” 22.1% vaped it in an e-cigarette or a vaping device, and 22.3% reported edible use. In a separate question about blunt use, 30.4% of past 30-day marijuana users used it as a blunt or spliff. In addition, among marijuana users, 52.7% (95% CI = 46.2%, 59.1%) also smoked tobacco (cigarette, cigar, pipe, or waterpipe; not reported in table).
Across the multinomial regression models there was a consistent pattern of decreased use by age and gender (Table 3). In the cigarette model the relative risk ratios (RRR) of exclusive marijuana use decreased with age (RRR = 9.66 among ages 18–24 vs RRR = 2.70 among ages 45–64) and was higher among males (RRR = 2.00) compared to females. A similar pattern was observed with dual use. Use of e-cigarettes and marijuana decreased with age (RRR = 56.81 among ages 18–24 vs RRR = 4.89 among ages 45–64). Similar to the cigarette model, the RRR of exclusive cigar use, exclusive marijuana, and dual use of cigar and marijuana decreased with age and were higher among males than females. Notably, the RRR of exclusive marijuana was higher among Non-Hispanic Black/African Americans compared to Non-Hispanic White in all models.
Discussion
The prevalence of cigarette smoking in 2018 among Minnesota adults was the lowest estimate compared to earlier surveys in the state (22.1% in 1999) (Centers for Disease Control and Prevention (CDC), Citation2011) and the use of other tobacco products was also low. However, the prevalence of past 30-day marijuana use (7.6%) was higher than non-cigarette tobacco products including e-cigarettes. This point estimate of past 30-day marijuana use can serve as a baseline if Minnesota moves forward to legalize marijuana for adult recreational use. Although the overall prevalence was low among all adults reporting both marijuana and tobacco in the past 30 days, young adult use was an exception. The finding of combusted tobacco being used by about half of marijuana users is consistent with previous studies (Pacek et al., Citation2018; Schauer et al., Citation2017). In addition, our finding that African American adults were more likely to use marijuana than non-Hispanic White adults has been reported in national data (Kennedy et al., Citation2016).
As policies to expand medicinal and recreational use of marijuana are considered in Minnesota and elsewhere, government agencies should anticipate the need to monitor trends and to plan surveys of sufficient sample size with questions on marijuana use (Ghosh et al., Citation2017). However, this will require refining questions to accurately assess the independent and concurrent use of both products. This is particularly relevant as some marijuana users who smoke blunts may not consider themselves to be tobacco users (Yerger et al., Citation2001).
Surveillance of marijuana use has increased as states have permitted medicinal and recreational use. Colorado allowed legal marijuana sales in 2014 and saw no change in past 30-day marijuana use among adults before and after legalization (13.6% vs 13.4%; Ghosh et al., Citation2017). A similar pattern was found in Washington state immediately after legalization (Everson et al., Citation2019). However, past 30-day marijuana use increased over time in both states, likely as more retail options became available (Colorado Department of Public Health and Environment, 2020; Everson et al., Citation2019). California has implemented an adult tobacco survey similar to Minnesota and this provides a comparison with our findings. In 2016, California adults’ use included 14.5% cigarette smoking, 5.6% e-cigarettes, 2.7% use of both marijuana and tobacco in the past 30 days, and marijuana prevalence was 9.5% (Apollonio et al., Citation2019). Nationally, in 2017/18 an estimated 10.6% of adults reported past 30-day marijuana use, an increase from 6.3% in 2008/9 (Substance Abuse & Mental Health Services Administration. (SAMHSA), 2019).
In late 2019, vaping products containing tetrahydrocannabinol (THC) increased in popularity especially by young people, and have been linked to serious lung injuries and deaths (Centers for Disease Control and Prevention (CDC), Citation2020). Although our survey did not include any questions about health effects, there is cause for concern as young adults in Minnesota preferred e-cigarettes (22.1%) compared to other tobacco products, and a non-trivial amount (9.2%) were dual users of e-cigarettes and marijuana. Future research should include sufficient sample to monitor product use including demographic differences in the relationship of marijuana use to other substances including tobacco, alcohol, and opiates. This is particularly relevant as population levels of tobacco use decline, and suggests a need to monitor the use of products together to understand concurrent use (McDonald et al., Citation2016).
Limitations
Our findings have limitations as the data are based on Minnesota residents who are self-reporting tobacco and marijuana use, which presents a risk of social desirability bias. Minnesota’s medicinal cannabis program was in place since 2015 (https://www.health.state.mn.us/people/cannabis/); however, faced with limited survey questions, specific questions about medicinal cannabis use were not assessed. Although the survey asked about blunt/spliff use, we did not ask other questions to link the temporal use of both marijuana and tobacco, or about the intensity of marijuana use. This limits our understanding of when and if tobacco and marijuana were used at the same time or on the same day. Additional questions about the initiation of tobacco and marijuana could facilitate our understanding of the interaction and influence of the early use of one substance on the later use of another and thus inform more effective tobacco and marijuana use prevention efforts (Kennedy et al., Citation2016).
Conclusions
As norms and policies related to marijuana use change, it will be important to track the use of tobacco and marijuana products separately and concurrently. Further research is needed to develop recommendations to accurately assess the use of marijuana and tobacco (Meier & Hatsukami, Citation2016). Reliable estimates of use and dual use will be important to the design of prevention and control efforts for both products (Kennedy et al., Citation2016).
Acknowledgments
This research was supported by Clearway Minnesota, a nonprofit tobacco control organization. ES and KL were supported by internal funds from Westat.
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