Associations between tobacco and cannabis use and anxiety and depression among adults in the United States: Findings from the COVID-19 citizen science study

Polysubstance use and mental health among young adults

OBJECTIVES

To describe mental health indicators according to regular (i.e., weekly or daily) alcohol, cannabis, and/or nicotine use in a population-based sample of young adults.

METHODS

Data for 733 participants (mean age = 30.6 years) were drawn from cycle 23 of the ongoing Nicotine Dependence In Teens study, Montreal, Canada. The associations between (i) number of substances used and (ii) pattern of polysubstance use and each of depressive symptoms, anxiety symptoms, and positive mental health (PMH) were modeled using multivariable linear regression adjusting for age, sex, and education.

RESULTS

Median (IQR) scores for depressive symptoms (range 0-50), anxiety symptoms (range 0-21), and PMH (range 0-70) were 8.0 (7.0), 4.0 (6.0), and 43.0 (18.0), respectively. One third (37%) of participants did not report regular use of any substance; 42%, 16%, and 5% reported regular use of one, two, or three substances, respectively. There was no dose-response association between number of substances used and any mental health indicator. Relative to no substance use, regular use of two substances was associated with more frequent anxiety symptoms ( β ^  [95% CI] = 1.32 [0.34, 2.31]) and lower PMH (-3.64 [-6.34, -0.95]). Specifically, the cannabis-nicotine combination was associated with more frequent anxiety symptoms (2.58 [1.06, 4.10]) and lower PMH (-5.90 [-10.04, -1.76]). The alcohol-nicotine combination was associated with lower PMH (-3.70 [-7.30, -0.10]).

CONCLUSION

Specific pairings of alcohol, nicotine, and cannabis may be important in their associations with mental health. Longitudinal studies in population-based samples of young adults are needed to replicate these findings before their implications for public health programming can be considered.

Prevalence and determinants of cigarette-cannabis co-use among US cancer survivors

PURPOSE

We estimated the prevalence of cigarette-cannabis co-use and investigated the individual-level factors associated with cigarette-cannabis co-use among adult (aged ≥ 18) cancer survivors.

METHODS

We used population-based data from the 2022 Behavioral Risk Factor Surveillance System. The sample included 9,323 (weighted 2,711,650) adult cancer survivors residing in 16 US states and two US territories. The outcome was cigarette-cannabis co-use, examined using multinomial multivariable logistic regression models.

RESULTS

Overall, 81.83% self-reported as white, 58.97% women, and 57.69% aged ≥ 65. About 12.00% reported current cigarette use, 10.36% past 30-day cannabis use, and 3.28% cigarette-cannabis co-use. The odds of cigarette-cannabis co-use were greater for younger survivors (18-49 years), those with high school or less education, not in the workforce, and divorced, separated, widowed, or never married individuals. Further, survivors with ≥ 3 comorbidities (vs. no-comorbidity), ≥ 14 days of poor mental health days (vs. none), and ≥ 14 days of poor physical health (vs. none) in the past month also had increased odds of cigarette-cannabis co-use.

CONCLUSIONS

The study findings suggest that certain subgroups of cancer survivors are more likely to engage in cigarette-cannabis co-use, and these patterns are associated with individual-level factors.

IMPLICATIONS FOR CANCER SURVIVORS

New strategies and tailored interventions targeting cigarette-cannabis co-use among cancer survivors are critically needed to improve the overall well-being of cancer survivors. Future research should explore additional factors to fully understand cigarette-cannabis co-use in cancer survivors.

Vaping nicotine and cannabis on the same occasion is linked to increased vaping consumption among young adults: A smartphone-based daily diary study

SIGNIFICANCE

Vaping both nicotine and cannabis in the past 30 days (co-vaping) is common among young adults. It is unclear which co-vaping patterns may increase substance use and dependence. We examined day-level associations between vaping patterns with vaping quantity.

METHOD

Daily assessments of vaping behaviors were collected via smartphone for 30 consecutive days among 111 young adults (aged 18-29, vaping nicotine/cannabis at least 20 days during the past month) in California, US, in 2023-2024. Participants reported daily use of nicotine/tobacco (e.g., e-cigarettes, cigarettes) and cannabis products (e.g., vaporized/combustible cannabis). Vaping intensities were the number of times a participant vaped nicotine/cannabis in an entire day. Vaping patterns on a given day were categorized into non-vaping, single-substance vaping, same-day different-occasion co-vaping, and same-occasion co-vaping. Generalized linear mixed-effect models examined day-level associations between these patterns and vaping intensity outcomes, controlling for covariates.

RESULTS

Of the participants, 84.7 % reported co-vaping and 15.3 % reported single-substance vaping in the past 30 days. Of the 2522 daily assessments, 42.7 % were nicotine-only vaping, 9.7 % cannabis-only vaping, 16.5 % same-day different-occasion co-vaping, and 16.9 % same-occasion co-vaping. Participants reported a greater intensity of vaping nicotine and cannabis on days with same-occasion co-vaping compared to days with other vaping patterns. Vaping intensities on days with same-day different-occasion co-vaping were greater than on days with single-substance vaping or non-vaping.

CONCLUSIONS

Closer temporal proximity of co-vaping was associated with greater intensities of vaping nicotine and cannabis. Same-occasion co-vaping is linked to the greatest increase in vaping intensity. Interventions addressing this high-risk pattern are warranted.

Urgent need for treatment addressing co-use of tobacco and cannabis: An updated review and considerations for future interventions

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.

Trends in cannabis and tobacco co-use in the United States, 2002-2021

BACKGROUND

Co-use of cannabis and tobacco poses greater risks than use of either substance individually and may be becoming more prevalent with increasing cannabis medicalization and legalization. We aimed to assess trends in the prevalence of cannabis and tobacco co-use between 2002-2019 and identify the updated prevalence and correlates of co-use in 2021 among US adults.

METHODS

This study used data from the 2002-2021 National Survey on Drug Use and Health, a nationally-representative, cross-sectional survey in the US. We assessed prevalence trends in past 30-day cannabis and tobacco co-use, exclusive cannabis use, and exclusive tobacco use overall and by sociodemographic group using joinpoint regression. Additionally, multinomial models identified correlates of co-use in 2021.

RESULTS

In 2021, the weighted prevalence of cannabis and tobacco co-use was 6.38 %, the weighted prevalence of exclusive cannabis use was 7.28 %, and the weighted prevalence of exclusive tobacco use was 15.01 %. From 2002 to 2019, the prevalence of past 30-day co-use of cannabis and tobacco increased significantly (annual percentage change [APC]: 1.9 [1.4-2.4], P<0.05) among the overall US population. All subgroups of sex, race/ethnicity, and age also saw significant increases in co-use, other than young adults ages 18-25, for whom co-use was stagnant between 2002-2014 and then decreased significantly between 2014-2019.

CONCLUSION

This study identified increasing cannabis and tobacco co-use overall and among most sociodemographic strata in the US. As cannabis policy changes rapidly, co-use requires closer surveillance, clinical screening, and dedicated research.

Factors Associated with Older People's Anxiety Symptom Positioning after COVID-19: Cross-Sectional Findings from a Canadian Sample

This study sheds light on the personal characteristics of older Canadians self-identifying as severely anxious and the coping strategies that they gravitated to mitigate their anxiety. Our studied sample consisted of 606 Canadians aged 60 and above who took part in an e-survey across all 10 of Canada's provinces, launched in July 2022, when social distancing was lifted across the country. Participants completed a personal characteristics questionnaire, the Geriatric Anxiety Scale or GAS-10, and a checklist of everyday coping strategies for mitigating anxiety. A seemingly greater number of severely anxious Canadians were born female, self-identified as a cisgender woman, and were in their 60s and in poor to fair health. A univariate logistic regression analysis revealed that all such personal characteristics were associated with statistically significantly greater odds of experiencing severe anxiety. In our multivariate logistic regression analysis, no significant differences were observed between the sexes (AOR = 0.590, p = 0.404), and non-binary and cisgender men (AOR = 0.689, p = 0.441) and women (AOR = 0.657, p = 0.397). Nor were there statistically significant differences in the odds of experiencing severe anxiety for those living with versus without a life partner and chronic illnesses. Older Canadians experiencing severe anxiety were far more likely to normalize their fear and anxiety (AOR = 4.76, p < 0.001), challenge their worries (AOR = 5.21, p < 0.001), and to relax or meditate (AOR = 2.36, p = < 0.001). They were less inclined to decrease other sources of stress in their lives, to stay active, and to get enough sleep. We offer anticipatory guidance for mental health program planners and practitioners, and fruitful avenues of inquiry for researchers.

A preliminary investigation of physical and mental health features of cannabis & nicotine co-use among adolescents and young adults by sex

INTRODUCTION

Cannabis and nicotine/tobacco products (NTP) are commonly co-used in adolescence and young adulthood; however, limited research has been done on predictive health behaviors to co-use. The current study is a preliminary investigation into the relationships of modifiable health behaviors on cannabis and NTP co-use in adolescents and young adults.

METHOD

221 participants (ages 16-22) were characterized into cannabis use only (N = 55), NTP use only (N = 20), cannabis and NTP co-use (used cannabis and NTP; N = 96) and control (no use; N = 50) groups based on past 30-day use. Self-report measures for physical activity, sleep quality, mental health, and reward responsivity were utilized. Participants were given a comprehensive neurocognitive battery. Logistic regressions of self-report measures and fluid intelligence composite scores on substance use group status were run stratified by sex.

RESULTS

Higher approach reward sensitivity traits were associated with increased likelihood of cannabis use only (Odds Ratio (OR) = 1.15, p = .036) in female participants. Increased aerobic activity was associated with decreased likelihood of cannabis use only (OR = 0.91, p = .047) and cannabis and NTP co-use (OR = 0.88, p = .007) in female participants. Higher anxiety was associated with increased likelihood of cannabis NTP co-use (OR = 1.51, p = 0.025) in male participants.

DISCUSSION

Several health behaviors were linked with cannabis use and cannabis and NTP co-use in both females and male adolescents and young adults. Health markers differed by sex suggesting differing mechanisms of substance co-use. This study informs targetable health behaviors for prevention and intervention efforts.

Situations and roles of cannabis versus cigarette use: Integrating ecological momentary assessment with qualitative mapping interviews

Use of both cannabis and tobacco has surpassed use of tobacco alone among young adults in California. To better understand why, we collected data with 32 young adults ages 18-30 in Northern California who regularly used cigarettes and cannabis and had diverse sexual, gender, racial, and ethnic identities. Geographically-explicit ecological momentary assessment (EMA; 30 days) was integrated with qualitative mapping interviews. We found contrasting situations of use for cannabis (e.g., around other people) versus cigarettes (e.g., recent discrimination) and different reasons for why participants chose one substance over the other (e.g., enhancing experiences vs. stepping away). Understanding when and why diverse young adults choose cannabis versus cigarettes as they navigate everyday environments helps explain how cannabis and tobacco retail markets shape substance use disparities over time.

Depression screening outcomes among adolescents, young adults, and adults reporting past 30-day tobacco and cannabis use

BACKGROUND

Few studies examine the relationship between depression and use of specific tobacco and/or cannabis products among adolescents, young adults, and adults. We determined whether the odds of depression are greater among those who used specific tobacco and/or cannabis products and among co-users of tobacco and cannabis.

METHOD

Cross-sectional online survey of a national convenience sample of 13-40-year-olds (N = 6,038). The survey included depression screening and past 30-day use of specific tobacco and cannabis products (cigarettes; e-cigarettes, vaped cannabis, little cigars, cigarillos, cigars, hookah, chewing tobacco, smoked cannabis, edible cannabis, blunts). Analyses correspond to the total sample, and 13-17-, 18-24-, and 25-40-year-olds.

RESULTS

Among 5,281 individuals who responded to the depression screener and nine product use questions, 1,803 (34.1 %) reported co-use of at least one tobacco product and one cannabis product in the past 30 days. Past 30-day co-use was associated with higher likelihood of screening positive for depression compared to past 30-day use of tobacco-only (aOR = 1.32, 1.06-1.65; 0.006) or cannabis-only (aOR = 1.94, 1.28-2.94; <0.001). Screening positive for depression was more likely among those who reported past 30-day use of e-cigarettes (aOR = 1.56; 1.35-1.80; <0.001), cigarettes (aOR = 1.24, 1.04-1.48; 0.016), chewed tobacco (aOR = 1.91, 1.51-2.42; <0.001), and blunts (aOR = 1.22, 1.00-1.48; 0.053) compared to those who did not report past 30-day use of these products. Among the 2,223 individuals who screened positive for depression, the most used two-product combination was nicotine e-cigarettes and smoked cannabis (614 individuals, 27.6 %).

CONCLUSIONS

Screening positive for depression was more likely among past 30-day co-users versus past 30-day users of tobacco-only or cannabis-only. Findings suggest that prevention programs for depression and substance use address tobacco and cannabis co-use.

Tobacco-cannabis co-use among cancer patients and survivors: findings from 2 US cancer centers

BACKGROUND

Cannabis use is prevalent among cancer patients and survivors and may provide some therapeutic benefits for this population. However, benefits may be attenuated when cannabis is co-used with tobacco, which is associated with more severe tobacco and cannabis use and adverse outcomes in noncancer populations. We compared cannabis use, primary mode of use, and therapeutic and/or nontherapeutic use among 3 groups of patients and survivors based on cigarette smoking status.

METHODS

Survey data was collected from patients and survivors with cancer (n = 1732) at 2 US National Cancer Institute-designated cancer centers in states with varying cannabis regulatory policy. Prevalence of cannabis use (prior to diagnosis, after diagnosis, before treatment, after treatment), primary mode of use, and therapeutic and/or nontherapeutic use were assessed by cigarette smoking status (current, former, never) within and across centers using weighted bivariate analyses and multivariable logistic regression, controlling for demographic and clinical variables.

RESULTS

Current cigarette use was associated with greater rates of cannabis use prior to diagnosis, after diagnosis, during treatment, and after treatment within each center (all P < .001) and in pooled analyses across centers (all P < .001). Primary mode of use, knowledge of cannabis products, and therapeutic and/or nontherapeutic use also statistically differed by tobacco status and study site.

CONCLUSIONS

Results illustrate the importance of conducting assessments for both tobacco and cannabis use among cancer patients during and after cancer treatment, regardless of the cannabis regulatory environment. Given previous data indicating harms from co-use and continued tobacco use during cancer treatment, this issue introduces new priorities for cancer care delivery and research.

Concurrent Use of Tobacco and Cannabis and Internalizing and Externalizing Problems in US Youths

Importance

Little is known about whether concurrent use of tobacco and cannabis is associated with higher or lower levels of mental health problems than use of either substance alone among youths.

Objective

To examine the association between concurrent use of tobacco and cannabis and mental health problems in a national sample of US youths.

Design, Setting, and Participants

This cross-sectional study analyzed publicly available wave 6 data within the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort study of US youths aged 14 to 17 years, collected from March to November 2021. This analysis used wave 6 single-wave weights to obtain statistically valid estimates for cross-sectional analyses generalizable to the wave 4 cohort sample. Data were analyzed from November 15, 2023, to April 20, 2024.

Exposure

Past 30-day use of any tobacco and cannabis products was self-reported and categorized into 4 exclusive patterns: concurrent, tobacco only, cannabis only, and nonuse.

Main Outcomes and Measures

Self-reported past-year internalizing and externalizing mental health problems were measured using the modified version of the Global Appraisal of Individual Needs-Short Screener and separately categorized into 3 levels: low (0-1 symptoms), moderate (2-3 symptoms), and high (≥4 symptoms).

Results

A total of 5585 youths were included in the study, with a weighted proportion of 51.3% being male and 72.5% aged 15 to 17 years. In terms of race and ethnicity, 1606 youths (25.7%) were Hispanic, 626 (12.7%) were non-Hispanic Black, 2481 (50.5%) were non-Hispanic White, and 555 (11.0%) were non-Hispanic other. The prevalence of concurrent use (3.4% [95% CI, 2.9%-4.0%]) was comparable to tobacco-only use (3.9% [95% CI, 3.2%-4.6%]), but greater than cannabis-only use (2.5% [95% CI, 2.1%-2.9%]). High levels of internalizing and externalizing problems were most common for the concurrent use group (internalizing: 47.4% [95% CI, 39.2%-55.9%]; externalizing: 61.6% [95% CI, 54.1%-68.7%]), followed by the cannabis-only use group (internalizing: 44.8% [95% CI, 35.7%-54.1%]; externalizing: 48.5% [95% CI, 39.1%-57.9%]), the tobacco-only use group (internalizing: 41.4% [95% CI, 33.7%-49.5%]; externalizing: 46.3% [95% CI, 38.3%-54.5%]), and the nonuse group (internalizing: 22.4% [95% CI, 21.1%-23.8%]; externalizing: 30.4% [95% CI, 28.9%-31.9%]). After controlling for covariates in ordinal logistic regression models, concurrent use of tobacco and cannabis was associated with greater odds of reporting higher levels of externalizing problems compared with tobacco-only use (adjusted odds ratio [AOR], 1.83 [95% CI, 1.15-2.91]) and cannabis-only use (AOR, 1.85 [95% CI, 1.11-3.06]). However, there were no statistically significant differences in the odds of internalizing problems between concurrent use and use of tobacco or cannabis alone.

Conclusions and Relevance

In this cross-sectional study of the PATH Study wave 6 youth data, concurrent use of tobacco and cannabis was linked to higher levels of externalizing mental health problems than use of single substances, indicating a potential need to combine mental health support with tobacco and cannabis cessation interventions for youths.

Exploring the Significance of Pharmaceutical Care in Mental Health: A Spotlight on Cannabis

Although preliminary evidence suggests Cannabis's efficacy in symptom control for anxiety and depression-psychiatric disorders that significantly impact mental health-much remains to be understood about its effects on the central nervous system (CNS) and how to optimize treatment for these disorders. This study aims to conduct a narrative review to evaluate pharmaceutical care in treating symptoms of anxiety and depression alongside Cannabis use, focusing on safety and therapeutic efficacy optimization. We seek to conceptualize anxiety and depression disorders, review evidence on Cannabis use, evaluate the evidence quality, and identify knowledge gaps. Twelve articles were identified, revealing a significant gap in the literature regarding the integration of pharmaceutical care with Cannabis-based therapies, specifically for anxiety and depression. Despite a growing interest in the relationship between Cannabis and mental health, current research is insufficient for a comprehensive understanding. The relationship between Cannabis use and anxiety and depression disorders requires further, more targeted investigations. This study underscores the importance of future research to fill existing gaps, providing informed insights and robust guidelines for the safe and effective use of Cannabis as part of the treatment for anxiety and depression. It is crucial that pharmaceutical care integrates these therapies responsibly to improve the overall well-being of patients.

Herbal Cannabis and Depression: A Review of Findings Published over the Last Three Years

Public perception contrasts scientific findings on the depression-related effects of cannabis. However, earlier studies were performed when cannabis was predominantly illegal, its production was mostly uncontrolled, and the idea of medical cannabis was incipient only. We hypothesized that recent changes in attitudes and legislations may have favorably affected research. In addition, publication bias against cannabis may have also decreased. To investigate this hypothesis, we conducted a review of research studies published over the last three years. We found 156 relevant research articles. In most cross-sectional studies, depression was higher in those who consumed cannabis than in those who did not. An increase in cannabis consumption was typically followed by an increase in depression, whereas withdrawal from cannabis ameliorated depression in most cases. Although medical cannabis reduced depression in most studies, none of these were placebo-controlled. In clinical studies published in the same period, the placebo also ameliorated depression and, in addition, the average effect size of the placebo was larger than the average effect size of medical cannabis. We also investigated the plausibility of the antidepressant effects of cannabis by reviewing molecular and pharmacological studies. Taken together, the reviewed findings do not support the antidepressant effects of herbal cannabis.

Distress about social problems and tobacco and cannabis use outcomes among young adults in Los Angeles County

OBJECTIVE

To examine associations of concern, worry, and stress about discrimination, shootings/violence, and police brutality and exclusive and dual tobacco and cannabis use among young adults.

METHODS

A prospective, racially/ethnically diverse cohort of young adults (n = 1960) living in Los Angeles, California completed a baseline survey in 2020 (age range: 19-23) and a follow-up survey in 2021. Exploratory factor analysis (EFA) was employed on nine variables assessing levels of concern, worry, and stress about societal discrimination, societal shootings/violence, and community police brutality at baseline. Past 30-day tobacco and cannabis use at follow-up was categorized as current exclusive tobacco, exclusive cannabis, and dual tobacco and cannabis (vs never/former) use based on eleven use variables. Multinomial logistic regressions estimated adjusted associations between each factor score (translated to standard deviation units) with exclusive and dual tobacco and cannabis use.

RESULTS

The EFA produced four factor scores representing concern/worry/stress (i.e., distress) about community police brutality (F1), distress about societal shootings/violence (F2), and distress about societal discrimination (F3), as well as generalized stress about police brutality, shootings/violence, and discrimination (F4). F1, F2, and F3 were associated with subsequent exclusive current cannabis use, with F1 having the strongest association (OR: 1.35, 95% CI: 1.18-1.55), while only F1 (OR: 1.51, 95% CI: 1.27-1.78) was associated with dual tobacco and cannabis use. None of the factors were associated with exclusive tobacco use.

CONCLUSIONS

Young adult concern, worry, and/or stress about social problems may increase risk of cannabis use with or without concurrent tobacco use 6-12 months later.