Co-use of cannabis, tobacco, and alcohol during adolescence: policy and regulatory implications

Abstract

Legislative reforms have legalized use of cannabis for medical and recreational purposes. Efforts to evaluate the public health impact of these changes have predominantly focused on determining whether liberalizing cannabis policies has increased cannabis use patterns. Co-use of cannabis and other licit substances, namely tobacco and alcohol, is common during the developmental period of adolescence, which is generally characterized by an increase in risk-taking and novelty-seeking. However, limited research has sought to evaluate the potential implications of reforms to medical and recreational cannabis laws on concurrent and simultaneous use of cannabis, tobacco, and alcohol during adolescence. The current report reviews the extant literature detailing the prevalence and outcomes associated with concurrent and simultaneous cannabis-tobacco and cannabis-alcohol use, including recent work that has examined how concurrent and simultaneous use may be influenced by cannabis reform. This review details how the cannabis landscape and cannabis retail marketplace have evolved and briefly summarizes the corresponding policy and regulatory challenges that have emerged. The report concludes with a focused cannabis co-use research agenda that adopts different strategies including behavioural economic, self-administration, and survey research methods.

Trends of poly-substance use among Canadian youth

“…All dual and triple substance combinations including this behaviour rose in prevalence towards the end of the examined period, with concurrent vaping and drinking particularly common. The association between e-cigarettes and alcohol, previously observed in other studies ( Morean et al, 2016 ; Schlienz & Lee, 2018 ; Taylor et al, 2017 ), together with data on social media trends ( Camenga et al, 2018 ; Chu et al, 2018 ; Sampasa-Kanyinga & Hamilton, 2018 ), indicates that use of the former is now a social activity ( Pepper et al, 2017 ; Yule & Tinson, 2017 ). This is particularly concerning not only in light of potential feedback effects due to the previously discussed outsize effects of peer behaviour, but also because e-cigarette use has been shown to increase the risk of cigarette smoking ( Barnett et al, 2015 ; Bold et al, 2018 ; Hammond et al, 2017 ), which also often co-occurs with alcohol use in social situations ( Berg et al, 2018 ; Gubner, Thrul, Kelly, & Ramo, 2018 ; Silveira et al, 2018 ), adding an additional layer of risk.…”

“…However, concerns regarding the impact of cannabis legalization on poly-substance use remain. This is because there may be a positive feedback loop between e-cigarette and cannabis use, partially due to cannabis vaping (which may increase following legalization) ( Borodovsky et al, 2017 ; Borodovsky, Crosier, Lee, Sargent, & Budney, 2016 ; Schlienz & Lee, 2018 ), and partially because each behaviour has been shown to be a risk factor for the other ( Audrain-McGovern, Stone, Barrington-Trimis, Unger, & Leventhal, 2018 ; Dai, Catley, Richter, Goggin, & Ellerbeck, 2018 ; Giroud et al, 2015 ; Peters, Bae, Barrington-Trimis, Jarvis, & Leventhal, 2018 ). Also, higher vaping prevalence has been shown to be associated with time elapsed since legalization ( Borodovsky et al, 2017 ), suggesting that prevention and intervention activities targeted to mitigating associated risks of poly-use will be required long-term.…”

Prevalence and Correlates of Simultaneous and Separate 30-Day Use of Tobacco and Cannabis: Results from the California Adult Tobacco Survey

“…These results suggest a transition toward modalities that allow simultaneous use, a trend that could continue or accelerate as these novel products become increasingly normalized. Research on simultaneous use suggests that such a transition would lead to more dependence and reduced quit attempts (Baggio et al, 2014; Schlienz & Lee, 2018), a concern given that these subpopulations are likely to have lower income (due to unemployment) and co-occurring conditions (disabilities).…”

“…Some users believe that combining tobacco with cannabis in a single occasion can enhance or prolong the psychoactive effects of cannabis use (Giroud et al, 2015), and those who vape tobacco and cannabis believe that vaping is a safe form of ingesting each substance (Giroud et al, 2015). Simultaneous use is associated with more symptoms of dependence, reduced motivation to quit, and greater social problems that separate use (Baggio, Studer, Mohler-Kuo, Daeppen, & Gmel, 2014; Schlienz and Lee, 2018), however, prevalence data assessing simultaneous use among other vulnerable population groups has been limited. These findings suggest a need to make explicit distinctions in surveillance data between two types of tobacco and cannabis use: (a) simultaneous use, meaning both products are consumed during the same occasion, and (b) separate use, in which respondents consume both products but do not do so during the same occasion.…”

Alcohol Use Disorder Increases Risk of Traumatic Brain Injury-Related Hospitalization: Insights From 3.8 Million Children and Adolescent Inpatients

“…About 75% of American teens who use cannabis also use alcohol. The use of more than one substance increases the likelihood of more than one SUD [29]. According to the substance abuse and mental health services administration (SAMSHA), 53% of adolescents who are binge drinking, reported last month tobacco use, and 30% of binge drinkers and 56% of tobacco users reported cannabis use in the same period [28].…”