Does Starting to Smoke Cigars Trigger Onset of Cannabis Blunt Smoking?

In our recent paper published in the January 2017 issue of the journal of Nicotine & Tobacco Research, we bring a spotlight on the relationship between cigar smoking and the risk of smoking cannabis blunts (i.e., rolling marijuana inside the hollowed-out shell of a tobacco cigar). In the US, nearly half of cannabis users smoke blunts and this proportion is likely higher among those most at risk for starting to use cannabis (i.e., ages 16-25). This is perhaps the first quantitative study to examine a modifiable, potential cause (i.e., cigar use) in the development of blunt smoking. Our findings show that starting to smoke cigars increases the immediate risk of starting to smoke blunts. However, the potential causes of blunt smoking remain understudied, and this initial finding needs to be replicated by stronger studies (e.g., longitudinal studies that gather data over multiple time points). I’ll discuss the paper and its findings in more detail below, followed by the abstract and link to the article.

This paper came about as an extension of my PhD dissertation work that examined the relationship between blunt smoking and symptoms of cannabis use disorder (CUD):

Fairman, B. J. (2015). Cannabis problem experiences among users of the tobacco-cannabis combination known as blunts. Drug and Alcohol Dependence, 150(May), 77–84.

In that paper, I found that those who smoked blunts had experienced higher levels of CUD compared to cannabis users who abstained from blunts. Subsequent to that work, I wanted to examine potential causal risk factors for starting to smoke blunts, and since cigars are integral into the construction of blunts, it made sense to start there.

The data we used for this paper came from the US National Surveys on Drug Use and Health (NSDUH), an annual survey of US households conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), which is a part of the US Department of Health and Human Services. This is a wonderful source of data for researchers, which contains data on about 55,000 people aged 12 years and older each year. We used a smaller subset of these data, aggregated over several years because we wanted to focus on individuals aged 12-21 years who had recently started to smoke blunts (almost 5,000 people).

Using a method called the case-crossover design, we compared the degree to which these new blunt smokers started smoking cigars in the preceding month compared to different control months. If there was no relationship between starting to smoke cigars and starting to smoke blunts, then the number of cigar onsets in the month before blunt onset should be no different than any other month. However, our data showed that cigar onsets were more likely to occur in the month prior to blunt onset than other months. This suggests that starting to smoke cigars may increase the risk of starting to smoke blunts in the next month.

However, there are several things to keep in mind regarding this finding: (1) This is the first study that has examined the cigar-blunt relationship, and as such, the finding should be replicated; (2) The finding does NOT suggest that prior cigar smoking will inevidably lead to smoking blunts, nor does it suggest that prior cigar smoking is the most likely cause of blunt smoking. Although we did not explicitly study this in the paper, most cigar smokers do not become blunt smokers. Indeed, even among those who recently started to smoke blunts, most reported no prior cigar smoking. Our paper only suggests that the month following cigar onset may be a period of heightened risk of starting to smoke blunts as compared to other months; (3) Our finding does NOT preclude other causes of starting to smoke blunts. Unfortunately, very few studies even collect data specific to blunts, so were limited in the types of hypotheses we could examine.

Since combining cannabis and tobacco, as in the case of blunts, could present unique public health challenges to the consequences of both substances, I think it is important to study blunt smoking and other forms of mixing these drugs. As more and more states remove barries to legal access to cannabis, this issue may become more important. Future studies will need examine a greater number of potential causal factors for blunt smoking using stronger study designs that gather data over time.

Does Starting to Smoke Cigars Trigger Onset of Cannabis Blunt Smoking?

(If you cannot access the article via Pubmed, then please see my Publications page that links to my ResearchGate or profile pages where you might have better luck. -BJF)

INTRODUCTION: Among United States teens during the 1990s, increasing cigar use coincided with increasing use of tobacco cigar shells filled with cannabis, called “blunts.” Cigar smokers are more likely to use cannabis, and we hypothesized that starting to smoke cigars might be a probabilistic “trigger” of blunt smoking. We turned to the case-crossover approach to evaluate this hypothesis.

METHODS: Within US National Surveys on Drug Use and Health, 2009-2013, we identified a nationally representative sample of newly incident blunt smokers aged 12- to 21-years-old (n = 4868) and compared month-of-onsets for smoking of cigars and blunts. Using the subjects-as-their-own-controls case-crossover design, we specified the first month prior to blunt use as a “hazard interval” and the second month prior to blunt use as a “control interval.” We used Mantel-Haenszel (MH) estimators to estimate the matched-pairs odds ratio (OR).

RESULTS: The MH OR estimate was 1.7 (95% CI = 1.3, 2.3), with excess odds of cigar onsets during the hazard interval relative to the control interval. Two alternative control interval specifications yielded congruent estimates (OR = 2.7 and 2.9, respectively).

CONCLUSIONS: A short interval right after starting to smoke cigars may be one of increased risk of starting to smoke blunts. We discuss cigar, cigarillo, and “blunt wraps” control approaches that might reduce both tobacco and cannabis-related harms.

IMPLICATIONS: If this evidence is correct, increased market-targeting to promote youthful cigar and cigarillo smoking might be followed by increased rates of blunt smoking in a vulnerable population. As noted by others, enhanced risk of smoking-attributable harms might be a consequence of mixed tobacco-cannabis formulations.

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