Next Article in Journal
Exploring Community Perspectives on Functional Paediatric Habitual Constipation
Previous Article in Journal
The Effects of Functional Training on the Ambulatory Blood Pressure and Physical Fitness of Resistant Hypertensive Elderly People: A Randomized Clinical Rehearsal with Preliminary Results
Previous Article in Special Issue
Sensitivity of Mouse Lung Nuclear Receptors to Electronic Cigarette Aerosols and Influence of Sex Differences: A Pilot Study
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
IJERPH
Volume 21
Issue 8
10.3390/ijerph21081016
ijerph-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Dual Use of Cannabis with Tobacco Is Associated with Increased Sugary Food and Drink Intake in Young People

by
Niamh Malhotra
1,
Nikita Kasaraneni
1,2,
Zoya Ahadian
1,
Howard Chang
1,2,
Ira Advani
1,2,
Jade McDermott
1,
Caitlyn Truong
1,
Samvel Gaboyan
1,2,
Ankita Mittal
1,
Alexia Perryman
1,2,
Jorge A. Masso-Silva
1,2,
Christine M. Steeger
3,
Russell P. Bowler
4,
Peter J. Castaldi
5,
Sunita Sharma
6 and
Laura E. Crotty Alexander
1,2,*
1
Division of Pulmonary, Critical Care, Sleep and Physiology, University of California San Diego, San Diego, CA 92093, USA
2
Pulmonary Critical Care Section, VA San Diego Healthcare System, San Diego, CA 92161, USA
3
Institute of Behavioral Science, University of Colorado Boulder, Boulder, CO 80309, USA
4
Department of Genomic Sciences and Systems Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
5
Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
6
Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO 80045, USA
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2024, 21(8), 1016; https://doi.org/10.3390/ijerph21081016
Submission received: 22 June 2024 / Revised: 22 July 2024 / Accepted: 26 July 2024 / Published: 2 August 2024
(This article belongs to the Special Issue Health Effects of Electronic Nicotine Delivery Systems (ENDS): What Can Be Learned from Human and Experimental Studies?)
Browse Figures
Versions Notes

Abstract

:
Rates of cannabis initiation among teenagers and young adults are increasing. Further, the use of various forms of cannabis (smoked or vaped) with nicotine (dual use) is increasingly common among young people. The health effects of dual use are lesser known, particularly in the context of high-potency cannabis products and across different routes of administration, which is ominous in terms of predicting future health outcomes. There is a long history of cannabis use being associated with decreased activity and increased snacking, both of which could portend an increased risk of metabolic and cardiovascular disease, particularly when these habits begin during formative years. However, modern forms of cannabis may not have these same effects. Here, we assess whether cannabis use alone and dual use of cannabis with nicotine impact dietary and exercise habits in young people. An anonymous, social media-based survey was designed based on the UC San Diego Inhalant Questionnaire and published diet and exercise questionnaires. A total of 457 surveys were completed. Young sole cannabis users represented 29% of responders, 16% were dual users of cannabis and nicotine, and 55% were non-users of either drug. Although the sole use of cannabis was not associated with dietary or activity differences relative to non-users, dual users of cannabis and nicotine reported higher consumption of unhealthy sugars. This novel finding of dual use being associated with increased sugar intake in young people raises concerns for an increased risk of metabolic syndrome and cardiovascular disease in this population.

1. Introduction

Given the recent legalization of cannabis in many states, the prevalence of its use has significantly increased among young people, with a staggering 245% increase in reported cases of abuse and misuse from 2000 to 2020 [1]. In particular, vaping tetrahydrocannabinol (THC) is increasing in popularity among young people, whereas other forms of cannabis consumption are declining in this group [2]. Cannabis use, including smoking marijuana, has anecdotally been associated with poor dietary habits, including binge eating, often referred to as “munchies” [3], and decreased physical activity [4]. Cannabis may also be associated with additional poor health practices due to the attitudes and behaviors associated with psychoactive or illicit drug use [5]. However, cannabis products have evolved drastically over the last few decades, such that the active and inactive ingredients across products are highly varied [6,7]. It is possible that smoking cannabis many years ago did cause unhealthy dietary and activity habits, whereas vaping THC, ingesting edibles, or smoking newer strains may not have the same effect [8,9]. Further, current popular strains of cannabis used in combustible products have different levels of active chemicals, such as Δ-8, Δ-9, and Δ-10-tetrahydrocannabinol, relative to historic strains, and vaped THC has different chemical levels relative to smoked forms of cannabis [10,11,12]. Overall, there is high variability in potency across cannabis products, and different products may have differing effects on addiction and mental and physical health outcomes [13]. We hypothesized that vaping THC would not lead to decreased activity but would be associated with unhealthy eating habits.
For many years, the use of combustible tobacco has declined among teenagers and young adults, from rates of 29.1% in 1997 to 5.4% in 2020 [14]. However, the rise of vaping nicotine (a form of tobacco) has blunted the overall decline in tobacco use [14]. Rates have been climbing again among youth, with 12.6% of high schoolers currently using tobacco products [15]. E-cigarettes are the most popular tobacco product, with 10% of high schoolers actively vaping nicotine [15]. We and other groups have found high rates of dual use of nicotine and cannabis products, both in young people and in adults [16,17]. Additionally, dual use is higher in lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other identities ([18] IA+) and Black, Indigenous, and People of Color (BIPOC) communities [19,20]. In contrast to cannabis, nicotine has been shown to have appetite suppressing effects [21,22]. Because studies have shown that nicotine and cannabis use habits and addiction often develop simultaneously among young people [23], there may be interactions between tobacco and cannabis products and their effects on diet and exercise. Further, data on the effects of the dual use of cannabis and tobacco on health remains limited. Overall, further research is needed regarding the independent impact of cannabis on overall health, as well as the impact of dual use on health [24].
Here, we assessed whether current forms of cannabis are associated with deleterious health effects in young people, including poor diet and minimal exercise. Because of the high rates of dual use with nicotine and the potential for the combination of these drugs to cancel out dietary and exercise effects, we also investigated whether the dual use of nicotine and cannabis has effects on diet and exercise. Click-through rates are higher with short online surveys, and completion rates are tightly tied to length as well. Thus, we designed the shortest possible survey (goal of <10 questions that take <2 min to complete) to obtain critical data from our population of interest, including age, cannabis use, and tobacco use [25,26].

2. Materials and Methods

2.1. Survey Instrument and Distribution

We conducted an online, anonymous survey over five months, from December 2021 to April 2022, to gather data from young people 13–21 years of age who gave informed consent (those aged 18 years or older) or assent (those <18 years of age). The survey instrument was distributed across social media platforms, including Reddit, Facebook, Instagram, and Twitter platforms. The survey was posted four times a week across all four sites by two separate team members.
This survey, entitled “Teenage General Health and Marijuana Use”, was distributed online and programmed with SurveyMonkey. It consisted of 8 core questions, which assessed self-reported demographic variables (age, gender, race, and ethnicity), smoking tobacco or vaping nicotine-containing e-cigarettes (with options of never, rarely, monthly, weekly, or daily use), and past and current cannabis use (options included edibles, smoked, vaped, or other), using questions adapted from the UCSD Inhalant Survey (Table 1) [27,28,29]. Questions about diet and exercise were derived from standardized surveys, with the exercise question designed from the Stanford Leisure-Time Activity Categorical Item with consolidation down to five answer options [30]. The diet question was derived from the 2001–2002 Health Behavior in School-Aged Children survey, with conversion into one matrix question. The subjects who reported current or prior cannabis use were given 3 additional questions in order to define the frequency of use and specific forms of cannabis used. Because online, social media-based survey click-through and completion rates are tightly tied to length (shorter surveys have higher click-through and completion rates), more detailed questions regarding cannabis and tobacco use were not included [25,26]. This study was approved by the institutional review board of the University of California San Diego.

2.2. Survey Responses

A total of 1256 surveys were completed and collected. Each participant who provided a valid email address was entered into a weekly lottery for a $250 Amazon gift card. The subjects were assigned a number, and the winners were selected through a random, blinded process using a random number generator. After the removal of computer generated (“bot”) responses (n = 29), incomplete responses (n = 7), and responses from subjects >21 years of age (n = 791), 457 surveys remained for analysis (Figure 1). The responses were categorized into four groups: controls (never or prior cannabis use), active cannabis users, nicotine users, and dual users (cannabis + the use of any form of inhaled nicotine).

2.3. Analysis

Age was analyzed as a continuous numeric variable, with ages 13–17 years combined because some groups had no subjects of these ages, across the four groups using Chi-squared tests. Gender (non-binary, gender variant/non-conforming, and prefer to self-describe were combined), race (prefer not to answer was combined with prefer to self-describe), and ethnicity were analyzed as nominal categorical variables across the four groups using Chi-squared tests (R version 4.4.1). Rcompanion (version 2.4.36) was used for post hoc analyses, using the pairwiseNominalIndependence function, with Bonferroni correction for multiple comparisons [31]. Diet and exercise habits were scored, with a lower score corresponding to a less healthy lifestyle. The diet and exercise data were analyzed as continuous numeric variables using the non-parametric Kruskal–Wallis test, with each group compared to the controls, and Dunn’s correction for multiple comparisons in GraphPad Prism version 10.3.0 (GraphPad Software, Boston, MA, USA). No outliers were identified or removed.

3. Results

3.1. Survey Responses

The online survey had a completion rate of 87%, with an average completion time of 2 min and 39 s, which accomplished our design goal of a short (<3 min) survey. Of the 457 teens and young adults who completed the survey, 44% reported active (within 30 days) cannabis use (n = 203; Table 2). The greatest number of participants were 21 years old (n = 120), with more active cannabis use in this age group (65%; n = 69). The majority identified as White (41%), Asian (34%), and Hispanic (23%; Table 2). Active cannabis users versus never/prior cannabis users were balanced on age, gender, race, and ethnicity.
Of the subjects reporting active cannabis use (n = 203; 44.4%), 14.8% (n = 30) reported using only edibles, 7.9% (n = 16) reported using only vape THC, 13.3% (n = 27) reported using edibles and smoking cannabis, 16.7% (n = 34) reported smoking and vaping cannabis, and 22.2% (n = 45) reported using edibles and smoking and vaping cannabis (Figure 2). Of the subjects reporting active tobacco use within the last 30 days (n = 95; 20.8%), the average age was 19.5 ± 1.3 years old, and 15.1% of females and 27% of males reported active tobacco use (Table 2). Of the tobacco users, 17.9% (n = 17) reported using only combustible cigarettes, 44.2% (n = 42) reported using only nicotine e-cigarettes, and 37.9% (n = 36) were dual users of both combustible cigarettes and nicotine e-cigarettes.
Sole users of cannabis represented 29% (n = 132), dual users of cannabis and nicotine e-cigarettes represented 7% (n = 31), dual users of cannabis and combustible tobacco represented 2% (n = 9), and triple users of cannabis, nicotine e-cigarettes, and combustible tobacco represented 7% (n = 31) of survey responders. Overall, dual users of both cannabis and nicotine represented 35% (n = 71) of active cannabis users and 16% of the overall cohort.

3.2. Diet and Exercise Habits

Higher sugary drink consumption was associated with dual use of both cannabis and nicotine relative to the controls (with a mean of 3.87 and 2.63, respectively, p < 0.0001; Figure 3A), as well as an increased intake of sweets (with a mean of 4.63 and 4.12, respectively, p = 0.015; Figure 3B). We observed no significant association between active cannabis use or dual use with fruit and vegetable consumption relative to the controls (Figure 3C,D). Self-reported exercise patterns were similar between active cannabis users, dual users, and non-users (Figure 3E).

4. Discussion

We examined the effects of cannabis with and without concomitant nicotine use among young people aged 13 to 21 years and identified an association between the dual use of both and higher unhealthy sugar intake. This is concerning because unhealthy sugar intake, including both sugary beverages and sugary foods, is known to increase the development of diabetes and metabolic syndrome, which then confer an increased risk of cardiovascular disease. Populations disproportionately affected by tobacco, including Hispanic, BIPOC, and LGBTQIA+ communities, already have an increased risk of these diseases, which contributes to higher burdens of morbidity and mortality [18,35,36]. Identifying additional drivers or contributors to disease in these at-risk populations, such as the dual use of cannabis and tobacco products, may help to shape public policies to combat them.
Our finding that the combination of nicotine and cannabis use is associated with increased sugar intake is very intriguing. In terms of the potential mechanisms, studies have found that cannabinoid receptor 1 (CB1) activation via THC binding reduces the release of the gamma-aminobutyric acid (GABA) neurotransmitter and increases caloric intake, which is potentially the underlying mechanism of the “munchies” effect [37]. Contrastingly, nicotine has been shown to have hypophagic effects (suppression of caloric intake) due to increased serotonin (5HT) and dopamine (DA) in the lateral hypothalamic area [21]. Surprisingly, we did not observe any increase in dietary consumption with active cannabis use alone, which is contrary to the widely held theory that cannabis use drives higher food intake in general [3]. Instead, our data suggest that the combination of cannabinoid and nicotinic receptor activation in the central nervous system, which occurs during dual use, is required to promote hyperphagic effects for unhealthy sugary foods and drinks. We hypothesize that this may be a result of chemo-sensory changes promoting a desire for sugar intake. For example, the combination of nicotinic and cannabinoid receptor activation may diminish sweet receptors in the tongue or decrease the signaling associated with sugar intake. Alternatively, the dual use of both cannabis and tobacco products may be an indicator of unhealthy lifestyle choices in general.
Another potential mechanism by which dual use leads to increased sugar intake is via the effects of cannabis and tobacco on stress responses. Studies have shown that the co-administration of nicotine and THC increases c-Fos immunoreactivity in various areas of the brain, such as limbic and cortical structures, involved in the stress response [38]. Most of these areas are innervated by dopamine inputs, which suggests that the activation of mesolimbic and mesocortical dopaminergic systems may allow for interactions between nicotine and THC or cannabinoids. Stress levels are well-known to have a wide range of effects on diet. To further explore whether the increased sugar intake of dual users is associated with the stress-related effects of THC and nicotine co-administration, further studies are needed that include questions designed to quantify stress levels along with our diet and exercise questions.
We found no evidence of cannabis use being associated with less exercise, either by itself or in combination with forms of tobacco, which is consistent with recent studies in this area [8,9,39]. Tobacco and cannabis users had similar exercise levels compared to the control subjects, indicating that the use of either product is not associated with unhealthy lifestyle choices in the realm of physical activity.
Our study has multiple limitations. Because this was a social media-based survey, self-reporting bias, sampling bias, and participation bias may have impacted the data. Also, we are only able to infer correlations between drug use and other variables, not causation. We obtained responses from few nicotine-only users (cigarette smokers and e-cigarette vapers), such that we cannot draw conclusions about the impact of nicotine alone on diet and exercise. However, our findings raise questions that could be answered by future studies, where a larger sample size would allow for investigation of the roles of sex, gender, race, ethnicity, and socioeconomic status on dietary changes in the setting of cannabis and tobacco use, both together (dual use) and individually. Controlling for weight and BMI, or looking at interaction effects with BMI, would be important in future studies. Further, mechanistic studies to investigate the impact of cannabis use, with and without nicotine, on diet and exercise may be critical to fully understand the health effects of these drugs, as the effects of each drug individually may be disparate from their health effects in combination. Objective measures of health behaviors would strengthen future research, in addition to THC and cannabidiol potency measures.

5. Conclusions

Dual users of tobacco and cannabis have a higher intake of unhealthy sweet food and drink. These data suggest that dual users of tobacco and cannabis may develop metabolic syndrome at higher rates, which would subsequently increase the risk of cardiovascular complications. Further, our study confirms what many other groups have found, that young people have high rates of dual use of cannabis and tobacco and have high rates of using multiple forms of cannabis and tobacco. It is critical to elucidate the short and long-term effects of the combined use of these drugs, particularly because habits developed during this stage of life may have lifelong implications. Further research in this area will be critical to guide policy makers and increase awareness among the general population, as well as to improve the health of teens and young adults.

Author Contributions

Conceptualization, N.M., N.K., I.A., A.M. and L.E.C.A.; methodology, N.M., N.K., H.C., I.A., A.M. and L.E.C.A.; software, L.E.C.A.; validation, L.E.C.A.; formal analysis, N.K., A.P. and L.E.C.A.; investigation, N.M., Z.A., H.C., I.A., J.M., C.T., S.G. and A.M.; resources, L.E.C.A.; data curation, N.M., Z.A., H.C., I.A., N.K., A.M., A.P., J.A.M.-S. and L.E.C.A.; writing—original draft preparation, N.M., N.K., Z.A., A.P., J.A.M.-S. and L.E.C.A.; writing—review and editing, N.K., A.P., J.A.M.-S., C.M.S., R.P.B., P.J.C., S.S. and L.E.C.A.; visualization, N.K., H.C., I.A., A.P., J.A.M.-S. and L.E.C.A.; supervision, A.P., J.A.M.-S., C.M.S., R.P.B., P.J.C., S.S. and L.E.C.A.; project administration, N.K., I.A. and L.E.C.A.; funding acquisition, L.E.C.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the Tobacco Related Disease Research Program (TRDRP), grant numbers T32SR5359 (PI LCA), T30IP0965 (PI LCA) and T33FT6629 (J.A.M-S), the NIH NHLBI, grant numbers K24HL155884 (PI LCA), R01HL147326 (PI PJC), and R01HL137052 (PI LCA), and the Department of Veterans Affairs (VA), Merit Award numbers 1I01BX004767 (PI LCA) and 1I01BX006447 (PI LCA). AP is a San Diego IRACDA Scholar supported by the NIH NIGMS K12 GM068524 Award.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of the University of California San Diego (protocol code 160204, date of approval: 7/5/2021).

Informed Consent Statement

Informed consent was obtained from all subjects greater than 18 years of age who were involved in the study. Patient assent was obtained from all subjects younger than 18 years of age. This study was conducted anonymously, such that the data gathered cannot be tracked back to the participant.

Data Availability Statement

Data is available upon request to the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

References

  1. Hughes, A.R.; Grusing, S.; Lin, A.; Hendrickson, R.G.; Sheridan, D.C.; Marshall, R.; Horowitz, B.Z. Trends in intentional abuse and misuse ingestions in school-aged children and adolescents reported to US poison centers from 2000–2020. Clin. Toxicol. 2023, 61, 64–71. [Google Scholar] [CrossRef] [PubMed]
  2. Keyes, K.M.; Kreski, N.T.; Ankrum, H.; Cerda, M.; Chen, Q.; Hasin, D.S.; Martins, S.S.; Olfson, M.; Miech, R. Frequency of adolescent cannabis smoking and vaping in the United States: Trends, disparities and concurrent substance use, 2017–2019. Addiction 2022, 117, 2316–2324. [Google Scholar] [CrossRef] [PubMed]
  3. Roberts, C.A.; Jager, G.; Christiansen, P.; Kirkham, T.C. Exploring the munchies: An online survey of users’ experiences of cannabis effects on appetite and the development of a Cannabinoid Eating Experience Questionnaire. J. Psychopharmacol. 2019, 33, 1149–1159. [Google Scholar] [CrossRef] [PubMed]
  4. Vidot, D.C.; Bispo, J.B.; Hlaing, W.M.; Prado, G.; Messiah, S.E. Moderate and vigorous physical activity patterns among marijuana users: Results from the 2007–2014 National Health and Nutrition Examination Surveys. Drug Alcohol. Depend. 2017, 178, 43–48. [Google Scholar] [CrossRef]
  5. Grigsby, T.J.; Lopez, A.; Albers, L.; Rogers, C.J.; Forster, M. A Scoping Review of Risk and Protective Factors for Negative Cannabis Use Consequences. Subst. Abuse 2023, 17, 11782218231166622. [Google Scholar] [CrossRef]
  6. EUDA. New analysis highlights greater diversity of cannabis products, rising potency, and security risks posed by Europe’s largest illicit drug market. In 2023 EU Drug Markets Analysis from the Emcdda and Europol; EUDA: Lisbon, Portugal, 2023. [Google Scholar]
  7. Smart, R.; Caulkins, J.P.; Kilmer, B.; Davenport, S.; Midgette, G. Variation in cannabis potency and prices in a newly legal market: Evidence from 30 million cannabis sales in Washington state. Addiction 2017, 112, 2167–2177. [Google Scholar] [CrossRef]
  8. Ong, L.Q.; Bellettiere, J.; Alvarado, C.; Chavez, P.; Berardi, V. Cannabis use, sedentary behavior, and physical activity in a nationally representative sample of US adults. Harm Reduct. J. 2021, 18, 48. [Google Scholar] [CrossRef] [PubMed]
  9. Kramer, A.; Sinclair, J.; Sharpe, L.; Sarris, J. Chronic cannabis consumption and physical exercise performance in healthy adults: A systematic review. J. Cannabis Res. 2020, 2, 34. [Google Scholar] [CrossRef]
  10. Stuyt, E. The Problem with the Current High Potency THC Marijuana from the Perspective of an Addiction Psychiatrist. Mo Med. 2018, 115, 482–486. [Google Scholar]
  11. Freeman, T.P.; van der Pol, P.; Kuijpers, W.; Wisselink, J.; Das, R.K.; Rigter, S.; van Laar, M.; Griffiths, P.; Swift, W.; Niesink, R.; et al. Changes in cannabis potency and first-time admissions to drug treatment: A 16-year study in the Netherlands. Psychol. Med. 2018, 48, 2346–2352. [Google Scholar] [CrossRef]
  12. Spindle, T.R.; Cone, E.J.; Schlienz, N.J.; Mitchell, J.M.; Bigelow, G.E.; Flegel, R.; Hayes, E.; Vandrey, R. Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Netw. Open 2018, 1, e184841. [Google Scholar] [CrossRef] [PubMed]
  13. Steeger, C.M.; Hitchcock, L.N.; Bryan, A.D.; Hutchison, K.E.; Hill, K.G.; Bidwell, L.C. Associations between self-reported cannabis use frequency, potency, and cannabis/health metrics. Int. J. Drug Policy 2021, 97, 103278. [Google Scholar] [CrossRef] [PubMed]
  14. Pierce, J.P.; Luo, M.; McMenamin, S.B.; Stone, M.D.; Leas, E.C.; Strong, D.; Shi, Y.; Kealey, S.; Benmarhnia, T.; Messer, K. Declines in cigarette smoking among US adolescents and young adults: Indications of independence from e-cigarette vaping surge. Tob Control 2023, 1–8. [Google Scholar] [CrossRef] [PubMed]
  15. Birdsey, J.; Cornelius, M.; Jamal, A.; Park-Lee, E.; Cooper, M.R.; Wang, J.; Sawdey, M.D.; Cullen, K.A.; Neff, L. Tobacco Product Use among U.S. Middle and High School Students—National Youth Tobacco Survey; MMWR; CDC: New York, NY, USA, 2023; Volume 72, pp. 1173–1182.
  16. Liu, J.; Hanby, E.; Kingsley, M.; Winickoff, J.P.; Gundersen, D.A.; Tan, A.S.L. Dual-Vaping of Nicotine and Cannabis among Adults Who Currently Use Tobacco Products in Five New England States. Nicotine Tob. Res. 2024, ntae062. [Google Scholar] [CrossRef] [PubMed]
  17. Dunbar, M.S.; Davis, J.P.; Tucker, J.S.; Seelam, R.; Rodriguez, A.; D’Amico, E.J. Parallel trajectories of vaping and smoking cannabis and their associations with mental and physical well-being among young adults. Drug Alcohol. Depend. 2023, 251, 110918. [Google Scholar] [CrossRef] [PubMed]
  18. Spanakis, E.K.; Golden, S.H. Race/ethnic difference in diabetes and diabetic complications. Curr. Diab. Rep. 2013, 13, 814–823. [Google Scholar] [CrossRef] [PubMed]
  19. Mattingly, D.T.; Patel, A.; Hirschtick, J.L.; Fleischer, N.L. Sociodemographic differences in patterns of nicotine and cannabis vaping among US adults. Prev. Med. Rep. 2022, 26, 101715. [Google Scholar] [CrossRef]
  20. Ramo, D.E.; Liu, H.; Prochaska, J.J. Tobacco and marijuana use among adolescents and young adults: A systematic review of their co-use. Clin. Psychol. Rev. 2012, 32, 105–121. [Google Scholar] [CrossRef] [PubMed]
  21. Miyata, G.; Meguid, M.M.; Fetissov, S.O.; Torelli, G.F.; Kim, H.J. Nicotine’s effect on hypothalamic neurotransmitters and appetite regulation. Surgery 1999, 126, 255–263. [Google Scholar] [CrossRef] [PubMed]
  22. Schwartz, A.; Bellissimo, N. Nicotine and energy balance: A review examining the effect of nicotine on hormonal appetite regulation and energy expenditure. Appetite 2021, 164, 105260. [Google Scholar] [CrossRef]
  23. Agrawal, A.; Lynskey, M.T.; Madden, P.A.; Pergadia, M.L.; Bucholz, K.K.; Heath, A.C. Simultaneous cannabis and tobacco use and cannabis-related outcomes in young women. Drug Alcohol. Depend. 2009, 101, 8–12. [Google Scholar] [CrossRef] [PubMed]
  24. Moustafa, A.F.; Rodriguez, D.; Pianin, S.H.; Testa, S.M.; Audrain-McGovern, J.E. Dual Use of Nicotine and Cannabis through Vaping among Adolescents. Am. J. Prev. Med. 2022, 63, 60–67. [Google Scholar] [CrossRef] [PubMed]
  25. Liu, M.; Wronski, L. Examining Completion Rates in Web Surveys via over 25,000 Real-World Surveys. Soc. Sci. Comput. Rev. 2017, 36, 089443931769558. [Google Scholar] [CrossRef]
  26. Göritz, A.S. Determinants of the starting rate and the completion rate in online panel studies1. In Online Panel Research; John Wiley & Sons, Ltd.: New York, NY, USA, 2014; pp. 154–170. [Google Scholar]
  27. Advani, I.; Gunge, D.; Boddu, S.; Mehta, S.; Park, K.; Perera, S.; Pham, J.; Nilaad, S.; Olay, J.; Ma, L.; et al. Dual use of e-cigarettes with conventional tobacco is associated with increased sleep latency in cross-sectional Study. Sci. Rep. 2022, 12, 2536. [Google Scholar] [CrossRef] [PubMed]
  28. Boddu, S.A.; Bojanowski, C.M.; Lam, M.T.; Advani, I.N.; Scholten, E.L.; Sun, X.; Montgrain, P.; Malhotra, A.; Jain, S.; Alexander, L.E.C. Use of Electronic Cigarettes with Conventional Tobacco Is Associated with Decreased Sleep Quality in Women. Am. J. Respir. Crit Care Med. 2019, 200, 1431–1434. [Google Scholar] [CrossRef] [PubMed]
  29. Gunge, D.; Marganski, J.; Advani, I.; Boddu, S.; Chen, Y.J.E.; Mehta, S.; Merz, W.; Fuentes, A.L.; Malhotra, A.; Banks, S.J.; et al. Deleterious Association of Inhalant Use on Sleep Quality during the COVID-19 Pandemic. Int. J. Environ. Res. Public Health 2021, 18, 13203. [Google Scholar] [CrossRef] [PubMed]
  30. Kiernan, M.; Schoffman, D.E.; Lee, K.; Brown, S.D.; Fair, J.M.; Perri, M.G.; Haskell, W.L. The Stanford Leisure-Time Activity Categorical Item (L-Cat): A single categorical item sensitive to physical activity changes in overweight/obese women. Int. J. Obes. 2013, 37, 1597–1602. [Google Scholar] [CrossRef] [PubMed]
  31. Mangiafico, S. rcompanion: Functions to Support Extension Education Program Evaluation [R Statistical Package]. 2016. Available online: https://CRAN.R-project.org/package=rcompanion (accessed on 22 July 2024).
  32. Ivan-balvan. Medical Marijuana Treatment Concept Stock Photo. Available online: https://www.istockphoto.com/photo/medical-marijuana-treatment-concept-gm1201521017-344609000 (accessed on 22 July 2024).
  33. Dmitry_Tishchenko. Weed Joint Macro of Cannabis Buds Marijuana with Trichomes and Crushed Weed Black Table Close Up. Available online: https://www.istockphoto.com/photo/weed-joint-macro-of-cannabis-buds-marijuana-with-trichomes-and-crushed-weed-on-a-gm948117958-258862148 (accessed on 22 July 2024).
  34. Skodonnell. Cannabis Joints and Brownies for Medicinal Use Stock Photo. Available online: https://www.istockphoto.com/photo/cannabis-joints-and-brownies-for-medicinal-use-gm1271218024-373888607 (accessed on 22 July 2024).
  35. Moore, J.X.; Chaudhary, N.; Akinyemiju, T. Metabolic Syndrome Prevalence by Race/Ethnicity and Sex in the United States, National Health and Nutrition Examination Survey, 1988–2012. Prev. Chronic Dis. 2017, 14, E24. [Google Scholar] [CrossRef] [PubMed]
  36. Prevention, United States Centers for Disease Control, Diabetes and the LGBTQ Community. Diabetes and the LGBTQ Community. Available online: https://www.cdc.gov/diabetes/risk-factors/diabetes-risk-lgbtq.html#:~:text=Lesbian%2C%20gay%2C%20bisexual%2C%20transgender,or%20bisexual%20women%20have%20it (accessed on 14 May 2024).
  37. Akbas, F.; Gasteyger, C.; Sjodin, A.; Astrup, A.; Larsen, T.M. A critical review of the cannabinoid receptor as a drug target for obesity management. Obes. Rev. 2009, 10, 58–67. [Google Scholar] [CrossRef]
  38. Valjent, E.; Mitchell, J.M.; Besson, M.J.; Caboche, J.; Maldonado, R. Behavioural and biochemical evidence for interactions between Delta 9-tetrahydrocannabinol and nicotine. Br. J. Pharmacol. 2002, 135, 564–578. [Google Scholar] [CrossRef]
  39. YorkWilliams, S.L.; Gust, C.J.; Mueller, R.; Bidwell, L.C.; Hutchison, K.E.; Gillman, A.S.; Bryan, A.D. The New Runner’s High? Examining Relationships Between Cannabis Use and Exercise Behavior in States with Legalized Cannabis. Front. Public Health 2019, 7, 99. [Google Scholar] [CrossRef] [PubMed]
Ijerph 21 01016 g001
Figure 1. Surveys included in the analysis.
Figure 1. Surveys included in the analysis.
Ijerph 21 01016 g001
Ijerph 21 01016 g002
Figure 2. Cannabis use patterns. Created with BioRender [32,33,34].
Figure 2. Cannabis use patterns. Created with BioRender [32,33,34].
Ijerph 21 01016 g002
Ijerph 21 01016 g003
Figure 3. Dual users of cannabis and nicotine have higher dietary sugar intake. Sole users of cannabis reported similar intake to non-users across the food groups (A–D) and similar exercise levels (E). Dual users of both cannabis and nicotine reported higher intake of sugary drinks (A) and sweets (B). * p < 0.05; **** p < 0.0001.
Figure 3. Dual users of cannabis and nicotine have higher dietary sugar intake. Sole users of cannabis reported similar intake to non-users across the food groups (A–D) and similar exercise levels (E). Dual users of both cannabis and nicotine reported higher intake of sugary drinks (A) and sweets (B). * p < 0.05; **** p < 0.0001.
Ijerph 21 01016 g003
Table 1. Cannabis and tobacco questions included on the UCSD Teen Cannabis and Tobacco Survey. Only the active use questions are shown. The past use questions were identical, but used past tense.
Table 1. Cannabis and tobacco questions included on the UCSD Teen Cannabis and Tobacco Survey. Only the active use questions are shown. The past use questions were identical, but used past tense.
Inhalant QuestionsAnswer Choices
Are you actively using any form of THC, marijuana, or CBD products? Including but not limited to: THC pens, edibles, joints, cannabis oils, etc. *Yes
No
Previous Usage
How many days per week do you currently use your THC products?Sliding scale from “less than once a week” to “every day”
On days that you use THC, how many times do you typically use the product(s) throughout the day?Sliding scale from “a couple times” to “a few times” to “constantly”
What forms of THC, cannabis, or CBD do you use? (choose all that apply)Edibles
Smoke
Vape
Other (please specify)
Have you ever used any of the following?
(select: Never, Rarely, Monthly, Weekly, or Daily)		Cigarettes
E-cigarettes
* Active use is defined as use within 30 days.
Table 2. Demographics of survey responders.
Table 2. Demographics of survey responders.
Controls
n = 230 (50.3%)		Cannabis Use
n = 132 (28.9%)		Nicotine Use
n = 24 (5.3%)		Cannabis +
Nicotine Use n = 71 (15.5%)		Overall
n = 457 (100%)		Chi-Squared Test
p Value
Post Hoc p Value
Age ** p = 0.004
$ p = 0.001
13 #4 (1.7%)0 (0%)0 (0%)0 (0%)4 (0.9%)
14 #5 (2.2%)0 (0%)0 (0%)0 (0%)5 (1.1%)
15 #3 (1.3%)0 (0%)0 (0%)0 (0%)3 (0.7%)
16 #4 (1.7%)0 (0%)0 (0%)1 (1.4%)5 (1.1%)
17 #8 (3.5%)3 (2.3%)1 (4.2%)4 (5.6%)16 (3.5%)
1844 (19.1%)13 (9.8%)3 (12.5%)16 (22.5%)76 (16.6%)
1967 (29.1%)32 (24.2%)6 (25%)12 (16.9%)117 (25.6%)
2054 (23.5%)35 (26.5%)4 (16.7%)18 (25.4%)111 (24.3%)
2141 (17.8%)49 (37.1%)10 (41.7%)20 (28.2%)120 (26.3%)
Average age:1919.919.819.419.4
Gender p = 0.10
Male106 (46.1%)62 (47.0%)18 (75.0%)44 (62.0%)230 (50.3%)
Female112 (48.7%)63 (47.7%)5 (20.8%)25 (35.2%)205 (44.9%)
Non-Binary #9 (3.9%)4 (3.0%)0 (0%)1 (1.4%)14 (3.06%)
Gender Variant/2 (0.9%)2 (1.5%)1 (4.2%)0 (0%)5 (1.09%)
Non-Conforming #
Prefer to Self-Describe #1 (0.4%)1 (0.8%)0 (0%)1 (1.4%)3 (0.65%)
Race ** p = 0.003
% p = 0.4
@ p = 0.04
American Indian or Alaska Native1 (0.4%)2 (1.5%)3 (12.5%)3 (4.2%)9 (1.97%)
Asian95 (41.3%)36 (27.3%)7 (29.2%)15 (21.1%)154 (33.7%)
Black or African American7 (3.0%)6 (4.5%)2 (8.3%)7 (9.9%)22 (4.81%)
White or Caucasian78 (33.9%)60 (45.5%)11 (45.8%)36 (50.7%)186 (40.7%)
Mixed19 (8.3%)13 (9.8%)1 (4.2%)4 (5.6%)36 (7.88%)
Prefer not to answer #20 (8.7%)9 (6.8%)0 (0%)1 (1.4%)30 (6.56%)
Prefer to self-describe #10 (4.3%)6 (4.5%)0 (0%)5 (7.0%)20 (4.38%)
Hispanic or of Latino Descent p = 0.7
Yes47 (20.4%)33 (25.0%)7 (29.2%)18 (25.4%)105 (23%)
No/Prefer not to Answer183 (79.6%)99 (75.0%)17 (70.8%)53 (74.6%)352 (77%)
# Because some values were 0–1, these categories were combined for the Pearson’s Chi-squared test. ** p < 0.01. $ Controls vs. Cannabis Use. % Control vs. Nicotine Use. @ Control vs. Dual Use.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Malhotra, N.; Kasaraneni, N.; Ahadian, Z.; Chang, H.; Advani, I.; McDermott, J.; Truong, C.; Gaboyan, S.; Mittal, A.; Perryman, A.; et al. Dual Use of Cannabis with Tobacco Is Associated with Increased Sugary Food and Drink Intake in Young People. Int. J. Environ. Res. Public Health 2024, 21, 1016. https://doi.org/10.3390/ijerph21081016

AMA Style

Malhotra N, Kasaraneni N, Ahadian Z, Chang H, Advani I, McDermott J, Truong C, Gaboyan S, Mittal A, Perryman A, et al. Dual Use of Cannabis with Tobacco Is Associated with Increased Sugary Food and Drink Intake in Young People. International Journal of Environmental Research and Public Health. 2024; 21(8):1016. https://doi.org/10.3390/ijerph21081016

Chicago/Turabian Style

Malhotra, Niamh, Nikita Kasaraneni, Zoya Ahadian, Howard Chang, Ira Advani, Jade McDermott, Caitlyn Truong, Samvel Gaboyan, Ankita Mittal, Alexia Perryman, and et al. 2024. "Dual Use of Cannabis with Tobacco Is Associated with Increased Sugary Food and Drink Intake in Young People" International Journal of Environmental Research and Public Health 21, no. 8: 1016. https://doi.org/10.3390/ijerph21081016

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop