Smoking tobacco along with marijuana increases symptoms of cannabis dependence

https://doi.org/10.1016/j.drugalcdep.2008.01.011Get rights and content

Abstract

Aim

User practices/rituals that involve concurrent use of tobacco and marijuana – smoking blunts and “chasing” marijuana with tobacco – are hypothesized to increase cannabis dependence symptoms.

Design

Ethnographers administered group surveys to a diverse, purposive sample of marijuana users who appeared to be 17–35 years old.

Setting

New York City, including non-impoverished areas of Manhattan, the transitional area of East Village/Lower East Side, low-income areas of northern Manhattan and South Bronx, and diverse areas of Brooklyn and Queens.

Participants

481 marijuana users ages 14–35, 57% male, 43% female; 27% White, 30% Black, 19% Latino, 5% Asian, 20% of other/multiple race.

Measurements

Among many other topics, group surveys measured cannabis dependence symptoms; frequencies of chasing, blunt smoking, joint/pipe smoking, using marijuana while alone, and general tobacco use; and demographic factors.

Findings

Blunt smoking and chasing marijuana with tobacco were each uniquely associated with five of the seven cannabis dependence symptoms. Across symptoms, predicted odds were 2.4–4.1 times greater for participants who smoked blunts on all 30 of the past 30 days than for participants who did not smoke blunts in the past 30 days. Significant increases in odds over the whole range of the five-point chasing frequency measure (from never to always) ranged from 3.4 times to 5.1 times.

Conclusions

Using tobacco with marijuana – smoking blunts and “chasing” marijuana with tobacco – contributes to cannabis dependence symptoms. Treatment for cannabis dependence may be more effective it addresses the issue of concurrent tobacco use.

Introduction

Cannabis addictive disorders are on the rise among Black and Latino youth (Compton et al., 2004). Conventional wisdom says that this is because marijuana is stronger today than in the past, but this explanation is inadequate on several levels. Recent reports that marijuana has increased in potency by factors of 10–20 are unsupported (European Monitoring Centre for Drugs and Drug Addiction, 2004, p. 52). The question of whether it actually has increased and by how much is complicated by the fact that marijuana is available in two general quality grades—“commercial” marijuana that is mass-produced and imported, and “designer” marijuana that is specially bred, locally grown, and carefully cultivated. Government studies often ignore this distinction, so increased availability of designer marijuana could cause a mistaken impression that marijuana in general is getting stronger. The Black and Latino youth under the increased burden from addictive disorders, however, usually smoke commercial marijuana (Sifaneck et al., 2007). Potency of commercial marijuana in the United States has only been validly observed to rise to the level it has maintained in European countries for several years. Finally, potency would only cause dependence in a linear dose–response fashion if users consistently smoked the same amount of marijuana, which they probably do not. Users do not set out to consume a certain amount of marijuana but to reach a certain “high” (Dunlap et al., 2005, Dunlap et al., 2006). Given stronger marijuana, they probably reach the desired effect faster and stop smoking sooner.

Smoking blunts and “chasing” marijuana with tobacco are popular among American urban youth. Blunts are made from shells of inexpensive cigars such as Phillies Blunts (their namesake), Backwoods, or Dutch Masters. Consumers split the cigars lengthwise, tip out the tobacco fillers or “blunt guts,” replace them with (usually) $10 worth of marijuana (about 1.5 g of commercial-grade marijuana or enough for three joints; see Sifaneck et al., 2007), roll the cigars back up, and share them among three or more smokers (Dunlap et al., 2005, Sifaneck et al., 2005). Blunts contain some residual tobacco, and some users actually prefer them for this reason. As an additional part of the practice/ritual, blunt users also sometimes pass around a tobacco cigarette or cigarillo “blunt chaser” such as a Black and Mild or Tiparillo immediately after the blunt is finished. Smoking tobacco and marijuana in combination and “chasing” marijuana with tobacco are common worldwide (Amos et al., 2004, Johnson et al., 2006). The practice of smoking joints – defined in the United States as marijuana rolled in a cigarette paper with no tobacco – is arguably exceptional for not necessarily involving any tobacco use.

Psychopharmacologically, blunts and “chasing” involve concurrent consumption of nicotine and cannabinoids, which interact in ways that have implications for abuse/dependence (Marco et al., 2006). According to a recent, thorough review of the research (Viveros et al., 2006), taking nicotine and cannabinoids together enhances the “reward” effect (Valjent et al., 2002), particularly for males (Penetar et al., 2005), although it may also enhance aversive (unpleasant) effects (Le Foll et al., 2006). Nicotine exacerbates the anxiolytic (anti-anxiety) and antinociception (anti-pain-perception; see Farquhar-Smith, 2002) effects of cannabinoids (Valjent et al., 2002). Nicotine and cannabis may also lessen each other's undesirable effects, i.e., Δ9-THC (delta-9-tetrahydrocannabinol, the primary psychoactive agent in marijuana) attenuates the anxiety-generating properties of nicotine (Balerio et al., 2006), and marijuana users report smoking tobacco to counteract the sedative effects of cannabis (Viveros et al., 2006).

Marijuana also reduces nicotine withdrawal symptoms (Balerio et al., 2004, Cohen et al., 2005a, Cohen et al., 2005b), perhaps because nicotine withdrawal involves the endogenous cannabinoid system (Castane et al., 2002, Castane et al., 2005). Although one might suspect, based on this, that marijuana users have more success in quitting tobacco, the available data indicate that marijuana use actually makes it harder to quit tobacco: “Difficulty in tobacco cessation might be considered one of the most important adverse effects of marijuana use” (Ford et al., 2002, p. 247). Daily cigarette smoking in adolescence is associated with marijuana and other substance use in young adulthood (Patton et al., 2006). A recent editorial in Addiction (Humfleet and Haas, 2004) and later research (Timberlake et al., 2007) describe findings that marijuana is a “gateway” to tobacco for many youth.

A logical next step in this line of inquiry is to look for a relationship between cannabis dependence and users’ actual smoking practices. This would require survey data, and use of fixed-response self-report data on dependence involves challenges to validity not present in laboratory research. Even if users accurately reported of amounts of marijuana and tobacco consumed, potencies of these products vary so widely that precise dosage of nicotine and cannabinoids could not be inferred (Sifaneck et al., 2007). Moreover, many users already firmly believe any dependence they have to be on nicotine, not cannabis (Dunlap et al., 2006), which could bias their survey responses.

Another challenge is that the validity of some individual criteria for cannabis dependence employed in the bulk of self-report research on cannabis dependence – those defined by the DSM-IV (American Psychiatric Association, 2000) and the ICD-10 (World Health Organization, 2004) – are in dispute (Dunlap et al., 2006, Soellner, 2005). Symptoms of physical tolerance and withdrawal from cannabis are mild relative to those of other drugs; some question their clinical significance (Soellner, 2005) or suggest that they might actually be a “rebound syndrome” of symptoms that the cannabis had been alleviating (Smith, 2002). Moreover, use of marijuana to relieve negative affect is not necessarily part of a dependence syndrome. Marijuana is arguably used to relieve negative effect because it works: Cannabinoids help extinguish aversive memories (Cannich et al., 2004, Chhatwal et al., 2005, Chhatwal and Ressler, 2007, Marsicano et al., 2002) and cannabis use is associated with lower depression among non-medical users (Denson and Earleywine, 2006a). Finally, it is also unclear whether the set of criteria for marijuana abuse/dependence describe a single dependence syndrome (Denson and Earleywine, 2006b, Soellner, 2005). Measures based on the DSM-IV and ICD-10 remain standard for survey research and use of them permits easy comparison with other studies, but future inquiry may discover better ways to operationalize cannabis abuse/dependence.

Earlier research (Compton et al., 2004) using standard measures of cannabis dependence documented an increase in cannabis use disorders, and this investigation raises the possibility that increased prevalence of practices involving concurrent use of marijuana and tobacco – using blunts and “chasing” marijuana with tobacco – contributed to this rise. Although our cross-sectional data cannot trace the prevalence of these practices and dependence symptoms over time, they can address the question of whether these practices are uniquely associated with cannabis dependence at all. Our analyses test the hypothesis that both greater frequency of chasing and greater frequency of blunts use – controlling for general tobacco use, use of marijuana in joints/pipes, using marijuana alone, and several demographic variables – contribute to cannabis dependence symptoms.

Section snippets

Participants and recruitment

Data for these analyses come from responses to the Peer Group Questionnaire (PGQ), the quantitative group survey component (see Ream et al., 2006, for details) that followed, and was greatly informed by, the ethnographic observation and qualitative interview component of a longitudinal mixed-methods study of marijuana users in various areas of New York City (Dunlap et al., 2005, Golub, 2006). Between January 2004 and April 2005, highly experienced ethnographers recruited groups of between 2 and

Independent and dependent variables

Table 1 describes rates at which participants reported the various cannabis dependence symptoms and the symptoms’ bivariate relationships with the tobacco and marijuana use variables. Joints/pipes use was associated with two cannabis dependence symptoms while blunts use was associated with six. Chasing blunts was associated with six dependence symptoms and chasing joints was associated with all seven. Both solitary use of blunts and solitary use of joints were associated with all seven

Discussion

These data confirm that marijuana use practices of smoking blunts and chasing marijuana with tobacco uniquely contribute to cannabis dependence symptoms. These findings hold even after controlling for solitary marijuana use, frequency of marijuana joint/pipe use, tobacco use, and several demographic factors including gender, race, age, recruitment location, and indicators of socioeconomic status. Previous research using animal models (Forget et al., 2005, Valjent et al., 2002, Viveros et al.,

Conflict of interest

No author on this manuscript has any personal or financial interest that would influence the results.

Acknowledgements

Preparation of this paper was supported by a grant from the National Institute on Drug Abuse (1R01 DA13690-05), and by National Development and Research Institutes. From April 2005 through August 2006, the first author was supported as a postdoctoral fellow in the Behavioral Sciences Training in Drug Abuse Research program sponsored by Medical and Health Association of New York City, Inc. (MHRA) and the National Development and Research Institutes (NDRI) with funding from the National Institute

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