Relationships between frequent cannabis use and tobacco use

Are there relationships between frequent cannabis use and tobacco use?

Smoking is a major public health concern bedeviling countries the world over. It does not only pose serious challenges to health development planning for governments but also places the lives of smokers, especially co-dependents, at high risk. Cannabis and tobacco, with shared modes of use, are the two world’s most used drugs, and their effects have been felt at national and global levels. According to Kristman-Valente, Hill, Epstein, Kosterman, Bailey, Steeger, Jones, Abbott, Johnson, Walker, and Hawkins (2017), tobacco use, for instance, is the leading preventable cause of deaths in the US. This is underlined by the fact that tobacco is more harmful than cannabis, with more tobacco smokers being nicotine dependent (Nutt et al., 2010). On the contrary, despite the prevalent use of marijuana, many users tend not to develop a dependence on the drug. All in all, the prevalence of cigarette and cannabis use varies along gender, racial, idiosyncratic, and socioeconomic variables.

While cigarette smoking has fallen significantly in the recent past, cannabis use has been on an upward trajectory over the same period. The effect of cannabis and tobacco co-use has particularly been placed in sharp focus in the wake of recent legislation aimed at legalizing marijuana across the world. Understanding the correlations between these two substances, thus, has the potential for substantial public health impact given that the two are independently associated with adverse health outcomes including, but not limited to, cancer, mental health impairment, chronic respiratory and cardiovascular problems, and substance abuse disorders. Used together, the effects of the two substances can be exacerbated (Kristman-Valente et al.,2017). Despite this, not much is known about the relationship between cigarette smoking and cannabis use and their combined effects (Hindocha Shaban, Freeman, Das, Gale, Schafer, Falconer, Morgan, and Curran, 2015). The gravity of this phenomenon cannot be overstated, given that 90% of cannabis smokers also identify as cigarette smokers, with half of the adults seeking treatment for cannabis use disorder (CUD) being cigarette smokers (Agarwal et al., ). More importantly, users of both show more severe symptoms of cannabis use disorder (CUD). They, however, point out that increased cigarette smoking may substitute for reduced cannabis smoking.

Recent research has gone some way to shed light on the relationship between frequent tobacco use and cannabis smoking. According to Hindocha et al. (2015), nicotine is more addictive than cannabis, and as such, cigarette smoking may be a primary driver of continued cannabis use and relapse in co-dependent smokers, and that there is a direct correlation between frequent cannabis use and tobacco use. They posit that cigarette smoking is related to concurrent cannabis dependence independent of the frequency of cannabis use. They also point out that there is a direct linkage between cannabis use and cannabis dependence, which may imply that tobacco-smoking has potential influence in driving cannabis dependence in young people. According to Kandel, Yaramaguchi, and Chen (1992), tobacco acts as a gateway drug to cannabis use, while Patton, Coffey, Carlin, Sawyer, and Lynskey (2005), on the other hand, posit that there is evidence to suggest the existence of a “reverse gateway” where cannabis use acts as an antecedent for future tobacco use. The physiological and psychological effects of both cannabis and tobacco use have also been the subject of research. According to David, Munafo, Johansen-Berg, Smith, Rogers, Matthews, and Walton (2005), for instance, nicotine and cannabis affect similar dopaminergic pathways, suggesting the existence of overlapping addiction mechanisms between the two. Hindocha et al. (2015), on the other hand, observe that the use of both drugs exhibits similar genetic, temperamental, and psychological factors. According to Agarwal and Lynskey (2009), with both drugs sharing the same routes of administration, there exists concurrent cross-sensitization between the two drugs, with tobacco use directly influencing the subjective effects of cannabis.

Generally, cannabis use disorder CUD) is caused by a multiplicity of factors including the age of onset, gender, impulsivity, mental health problems, and early start of continued tobacco smoking. Van der Pol, Liebgrets, de Graaf, Korf, van den Brink, and van Laar (2013) posit that adverse life events and social support factors, or lack thereof, such as living alone, were significant predictive factors of cannabis use disorder (CUD).

With the effects of co-dependence on cannabis and tobacco often being fatal for users, there is a need to develop frameworks to help alleviate their dependence on the two substances and eventually, cessation of use. There have been robust efforts geared towards fighting tobacco use. Unfortunately, not much has been done to discourage cannabis use. According to Kristman-Valente et al. (2017), conventional cigarette smoking efforts could go a long way to decrease late marijuana use among adults and that if such initiatives are focused early enough on young adults as they transition to adulthood, the prevalence of cigarette and marijuana use will drop significantly.

Are there relationships between routes of administration and intention for cessation?

Cannabis and tobacco are the two most abused drugs worldwide, with tobacco accounting for more than one billion users worldwide (Agrawal and Lynskey, 2009). Cannabis, on the other hand, is the most commonly used illicit drug globally, accounting for almost 174 million users globally. According to Twyman, Bonevski, Paul, Kay-Lambkin, Bryant, Oldmeadow, Pallazi, and Guillaumier (2016), cannabis smokers are four to nine times more likely to be regular tobacco smokers, compared with non-cannabis users. Cannabis possesses the potential to act as a ‘gateway’ to tobacco use and can play a crucial role in supporting and reinforcing cigarette smoking. This has become the subject of much scholarly research given that cannabis and tobacco smoking can occur either concurrently or simultaneously. Agrawal and Lynskey (2009) also point out that  tobacco and cannabis are often used in combination through various routes of administration (ROA) despite considerable global differences in cannabis and tobacco routes of administration, with tobacco routes of administration being more common, especially in Europe. Much of the research examining cannabis and tobacco use has unfortunately failed to show the association and distinctions between the two abused substances, with their being conflations about the various routes of administration and their effects, thus derailing the fight against cannabis and tobacco abuse.

According to Agrawal and Lynskey (2009), a robust understanding of the various routes of administration such as the use of vaporizers and smoking of “tobacco joints” can play a significant role in the cessation of use of both cannabis and tobacco despite the variances between the effects of cannabis vis-à-vis routes of administration. According to Agrawal and Lynskey (2019), smokers of tobacco generally portray poor cessation outcomes as compared to “pure” cannabis smokers, with tobacco being more problematic for those who are co-dependent on the two drugs. Hindocha et al. (2015) confirm this, postulating that non-tobacco-based routes of administration are associated with increased desire to use less tobacco, despite there being inconsistencies in findings of the effects of routes of administration on “pure” cannabis use. Some research findings, however, point out that the association of cannabis smoking with cannabis amotivational syndrome may be a barrier to change for those who want to quit their dependence on the same as motivation is an important aspect of cessation.

The development of various non-tobacco routes of administration has also had a profound effect on motivation to quit cannabis and tobacco smoking with an increase in the number of routes of administration being associated with heavier tobacco, cannabis, and illicit drug use (Baggio et al., 2014). One of the main non-tobacco routes of administration that has grown popular in the recent past is the use of vaporizers, devices that electronically heat up cannabis to produce inhalable vapor without combustion, and that are considered less harmful than smoked cannabis or tobacco. Agarwal and Lynskey (2009) point out that the use of vaporizers can lead to reduced tobacco consumption.

There is consensus in research findings that tobacco-based routes of administration portend the most substantial challenge to cannabis and tobacco use cessation. According to Agrawal and Lynskey (2009), there is an increased risk of cannabis use and abuse or dependence for tobacco smokers, and as such, tobacco routes of administration are associated with a reduced motivation to lessen tobacco use and more negative impacts of cannabis. It is for this that Hindocha et al. (2016) conclude that tobacco cessation programs for those who smoke cannabis should focus on non-tobacco routes of administration as this is more likely to increase the chances and effectiveness of quitting attempts. More importantly, Twyman et al. (2016), also introduce an interesting contribution to the study of motivation and intentions of quitting tobacco and cannabis smoking. They argue that a high level of socioeconomic disadvantage is linked to increased tobacco and cannabis use and that failure to address this may derail or prolong the fight against drug dependence as such conditions are likely to compound poor health outcomes for affected individuals.

References

Hindocha, C., Freeman, T. P., Ferris, J. A., Lynskey, M. T., and Winstock A. R. () No smoking without tobacco: A global overview of cannabis and tobacco routes of administration and their association with intention to quit. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337852/!po=35.3933

Kristman-Valente, A. N., Hill, K. G., Epstein, M., Kosterman, R., Bailey, J. A., Steeger, C. M., Jones, T. M., Abbott, R. D., Johnson, R. M., Walker, D., and Hawkins, J. D. (2017) The relationship between marijuana and conventional cigarette smoking behavior from early adolescence to adulthood. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5505066/|_ffn_sectitle

Kandel, D. B., Yamaguchi, K., and Chen, K. (1992) Stages of progression in drug involvement from adolescence to adulthood: Further evidence for the gateway theory. Journal of Studies on Alcohol and Drugs, 53:447

Van der Pol, P., Liebgrets, N., de Graaf, R., Korf, D. J., van den Brink, W., and van Laar, M. (2013) Predicting the transition from frequent cannabis use to cannabis dependence: A three-year prospective study. Drug and Alcohol Dependence, 133: 352-359

Twyman, L., Bonevski B., Paul, C., Kay-Lambkin, F. J., Bryant, J., Oldmeadow, C., Palazzi, K., and Guillaumier, A. (2016) The association between cannabis use and motivation and intentions to quit tobacco within a sample of Australian socioeconomically disadvantaged smokers. Health Education Research, Volume 31, Issue 6.

Agrawal, A. and Lynskey, M. T. (2009) Tobacco and cannabis co-occurrence: Does route of administration matter? Drug and Alcohol Dependence, 99(1-3), 240-247.

Hindocha, C., Shaban, N. D. C., Freema, T. P., Das, R. K., Gale, G., Shafer, G., Falconer, C. J., Morgan, C. J. A., AND Curran, H. V. (2015) Association between cigarette smoking and cannabis dependence: A longitudinal study of young cannabis users in the United Kingdom.  Drug and Alcohol Dependence, 148, 165-171.

Patton, G. C., Coffey, C., Carlin, J. B., Sawyer, S. M., and Lynskey, M. (2005) Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence. Addiction. 100: 1518-1525.

Agrawal, A., Budney, A. J., and Lynskey, M. T. (2012) The co-occurring use and misuse of cannabis and tobacco: A review. Addiction Volume 107: 1221-1233

Baggio, S., Deline, S., Studer, J., Mohler-Kuo, M., Daeppen, J. B., and Gmel, G. (2014) Routes of administration of cannabis used for nonmedical purposes and associations with patterns of drug use. Journal of Adolescent Health, Vol 54: 235-240.

David, S. P., Munafo, M. R., Johansen-Berg, H., Smith, S. M., Rogers, R. D., Matthews, P. M., and Walton R. T. (2005) Ventral striatum/ nucleus accumbens activation to smoking-related pictorial cues in smokers and non-smokers: A functional magnetic resonance imaging study. Biological Psychiatry Volume 58: 488-494

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