Digital health for assessment and intervention targeting tobacco and cannabis co-use

Classification of patterns of tobacco and cannabis co-use based on temporal proximity: A qualitative study among young adults

PURPOSE

Co-use of tobacco and cannabis is a common and complex behavior. The lack of harmonized measures of co-use yields confusion and inconsistencies in synthesizing evidence about the health effects of co-use. We aimed to classify co-use patterns based on temporal proximity and describe preferred products and motives for each pattern in order to improve co-use surveillance.

METHODS

We conducted semi-structured interviews in a sample of 34 young adults (Mage = 22.8 years, 32.4 % female) during 2017-2019 in California, USA. We employed a qualitative thematic analysis to identify timing, reasons, and contexts for tobacco and cannabis co-use and classify co-use patterns.

RESULTS

Four emergent patterns of co-use with increasing temporal proximity between tobacco use and cannabis use were: Same-month different-day co-use (Pattern 1); Same-day different-occasion co-use (Pattern 2); Same-occasion sequential co-use (Pattern 3); and Same-occasion simultaneous co-use (Pattern 4). Participants used various product combinations within each pattern. Similar motives for all patterns were socialization, product availability, and coping with stress/anxiety. Unique motive for temporally distant patterns (Patterns 1 and 2) was seeking substance-specific effects (e.g., stimulant effect from nicotine, relaxation effects from cannabis), while unique motives for temporally close patterns (Patterns 3 and 4) were seeking combined effects from both substances (e.g., more intense psychoactive effects, mitigating cannabis adverse effects) and behavioral trigger (e.g., cannabis use triggers tobacco use).

CONCLUSIONS

Our classification of co-use patterns can facilitate consistency for measuring co-use and assessing its health impacts. Future research should also measure product types and motives for different patterns to inform intervention efforts.

Quantity of cigarettes smoked when co-used with alcohol and cannabis: Consideration of different definitions of co-use based on daily diary data

INTRODUCTION

Cigarettes are frequently co-used with alcohol and cannabis. However, definitions of co-use vary and the extent to which cigarette use changes on days with different patterns of co-use is unclear. We compared the number of cigarettes smoked on different days based on co-use patterns of cigarettes and alcohol or cannabis.

METHODS

This study analyzed 2408 smoking days collected in a 30-day smartphone-based daily diary study among 146 young adults (aged 18-26) with an oversample from sexual minority groups. Two separate multilevel models were estimated: one for cigarette and alcohol co-use and the other for cigarette and cannabis co-use. Both models examined day-level associations between the number of cigarettes smoked and 3 different types of days (smoking-only days, same-occasion co-use days, different-occasion co-use days), controlling for demographic characteristics.

RESULTS

More cigarettes were smoked on same-occasion co-use days compared to cigarette-smoking-only days for both alcohol (b=1.474, SE=0.136, t=10.8, p<.001) and cannabis (b=0.822, SE=0.209, t=3.9, p<.001). There were no significant differences in cigarettes smoked on days with co-use on the same day, but on different occasions, compared to days with smoking only.

CONCLUSIONS

Compared to days with cigarette smoking only, more cigarettes are smoked on days when cigarettes are co-used with alcohol or cannabis on the same occasion, while the same is not true for days with co-use on different occasions. Conflating different definitions of co-use may impact findings on associations between co-use and smoking behavior.

Associations Between Product Type and Intensity of Tobacco and Cannabis Co-use on the Same Day Among Young Adult Smokers: Smartphone-Based Daily-Diary Study

BACKGROUND

Co-use of tobacco and cannabis is highly prevalent among young US adults. Same-day co-use of tobacco and cannabis (ie, use of both substances on the same day) may increase the extent of use and negative health consequences among young adults. However, much remains unknown about same-day co-use of tobacco and cannabis, in part due to challenges in measuring this complex behavior. Nuanced understanding of tobacco and cannabis co-use in terms of specific products and intensity (ie, quantity of tobacco and cannabis use within a day) is critical to inform prevention and intervention efforts.

OBJECTIVE

We used a daily-diary data collection method via smartphone to capture occurrence of tobacco and cannabis co-use within a day. We examined (1) whether the same route of administration would facilitate co-use of 2 substances on the same day and (2) whether participants would use more tobacco on a day when they use more cannabis.

METHODS

This smartphone-based study collected 2891 daily assessments from 147 cigarette smokers (aged 18-26 years, n=76, 51.7% female) during 30 consecutive days. Daily assessments measured type (ie, cigarette, cigarillo, or e-cigarette) and intensity (ie, number of cigarettes or cigarillos smoked or number of times vaping e-cigarettes per day) of tobacco use and type (ie, combustible, vaporized, or edible) and intensity (ie, number of times used per day) of cannabis use. We estimated multilevel models to examine day-level associations between types of cannabis use and each type of tobacco use, as well as day-level associations between intensities of using cannabis and tobacco. All models controlled for demographic covariates, day-level alcohol use, and time effects (ie, study day and weekend vs weekday).

RESULTS

Same-day co-use was reported in 989 of the total 2891 daily assessments (34.2%). Co-use of cigarettes and combustible cannabis (885 of the 2891 daily assessments; 30.6%) was most commonly reported. Participants had higher odds of using cigarettes (adjusted odds ratio [AOR] 1.92, 95% CI 1.31-2.81) and cigarillos (AOR 244.29, 95% CI 35.51-1680.62) on days when they used combustible cannabis. Notably, participants had higher odds of using e-cigarettes on days when they used vaporized cannabis (AOR 23.21, 95% CI 8.66-62.24). Participants reported a greater intensity of using cigarettes (AOR 1.35, 95% CI 1.23-1.48), cigarillos (AOR 2.04, 95% CI 1.70-2.46), and e-cigarettes (AOR 1.48, 95% CI 1.16-1.88) on days when they used more cannabis.

CONCLUSIONS

Types and intensities of tobacco and cannabis use within a day among young adult smokers were positively correlated, including co-use of vaporized products. Prevention and intervention efforts should address co-use and pay attention to all forms of use and timeframes of co-use (eg, within a day or at the same time), including co-use of e-cigarettes and vaporized cannabis, to reduce negative health outcomes.

Longitudinal Associations Between Use of Tobacco and Cannabis Among People Who Smoke Cigarettes in Real-world Smoking Cessation Treatment

OBJECTIVES

Cannabis use is common among people who use tobacco. However, little is known about the relationship between change in use of tobacco and cannabis over time. We examined the longitudinal associations between use of the two substances in a realworld smoking cessation context.

METHODS

This study analyzed data from a 3-month smoking cessation program delivered via Facebook in the San Francisco Bay Area, USA during 2016-2020. The sample included 487 participants who smoked cigarettes ( Mage = 25.4 years old, 39.6% Male, 40.3% White). The regressors (ie, frequency or number of days during the past 30 days using cigarettes, e-cigarettes, and cigars) and the outcome (ie, frequency of cannabis use) were measured at both baseline and 3-month follow-up. Random-effects modeling examined the longitudinal associations between the regressors and the outcome controlling for alcohol use and baseline demographics.

RESULTS

Participants who increased (or decreased) their frequency of use of cigarettes (β = 0.17, 95% confidence interval [CI] = 0.10, 0.24), e-cigarettes (β = 0.11, 95% CI = 0.05, 0.17), or cigars (β = 0.19, 95% CI = 0.06, 0.32) also increased (or decreased) their frequency of cannabis use after 3 months. Sexual minority participants (vs heterosexuals) (β = 2.12, 95% CI = 0.01, 4.24) and those whose education attainment being high school or less (vs higher education) (β = 3.89, 95% CI = 1.25, 6.53) were more likely to increase their frequency of cannabis use over time.

CONCLUSIONS

The findings indicated positive associations between change in use of tobacco and cannabis use. Promoting cessation among people who use tobacco may help to reduce their cannabis use.

Opportunities for Smartphone Sensing in E-Health Research: A Narrative Review

Recent years have seen significant advances in the sensing capabilities of smartphones, enabling them to collect rich contextual information such as location, device usage, and human activity at a given point in time. Combined with widespread user adoption and the ability to gather user data remotely, smartphone-based sensing has become an appealing choice for health research. Numerous studies over the years have demonstrated the promise of using smartphone-based sensing to monitor a range of health conditions, particularly mental health conditions. However, as research is progressing to develop the predictive capabilities of smartphones, it becomes even more crucial to fully understand the capabilities and limitations of using this technology, given its potential impact on human health. To this end, this paper presents a narrative review of smartphone-sensing literature from the past 5 years, to highlight the opportunities and challenges of this approach in healthcare. It provides an overview of the type of health conditions studied, the types of data collected, tools used, and the challenges encountered in using smartphones for healthcare studies, which aims to serve as a guide for researchers wishing to embark on similar research in the future. Our findings highlight the predominance of mental health studies, discuss the opportunities of using standardized sensing approaches and machine-learning advancements, and present the trends of smartphone sensing in healthcare over the years.

Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies

BACKGROUND

Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women.

METHODS

We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use.

RESULTS

Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR_{/5 yrs}: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39).

CONCLUSION

Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.

Applications of technology in the assessment and treatment of cannabis use disorder

Cannabis use and Cannabis Use Disorder (CUD) have been increasing. There are no FDA approved medications and evidence-based psychotherapy is limited by insufficient providers, serving very few patients effectively. The lack of resources for prevention and treatment of CUD has resulted in a significant gap between the need for services and access to treatment. The creation of a scalable system to prevent, screen, refer and provide treatment for a chronic, relapsing diagnosis like CUD could be achieved through the application of technology. Many studies have utilized ecological momentary assessments (EMA) in treatment seeking and non-treatment seeking cannabis users. EMA allows for repeated, intensive, longitudinal data collection in vivo. EMA has been studied in cannabis use and its association with affect, craving, withdrawal, other substances, impulsivity, and interpersonal behaviors. EMA has the potential to serve as a valuable monitoring tool in prevention, screening, and treatment for CUD. Research has also focused on the development of internet and application-based treatments for CUD, including a currently available prescription digital therapeutic. Treatment options have expanded to more broadly incorporate telehealth as an option for CUD treatment with broad acceptance and change in regulation following the COVID-19 pandemic. While technology has limitations, including cost, privacy concerns, and issues with engagement, it will be a necessary medium to meet societal health needs as a consequence of an ever-changing cannabis regulatory landscape. Future work should focus on improving existing platforms while ethically incorporating other functions (e.g., sensors) to optimize a public and clinical health approach to CUD.

Alcohol, marijuana, and nicotine use as predictors of impaired driving and riding with an impaired driver among college students who engage in polysubstance use

OBJECTIVE

While alcohol, marijuana, and nicotine are the most commonly used substances, there is limited research on the between- and within-person associations of their use and driving under the influence (DUI) and riding with an impaired driver (RWID). The current study utilized a burst design to assess how use and co-use of these substances is associated with DUI and RWID.

METHODS

College student drinkers with past-year marijuana and/or nicotine use (N = 367) were assessed on two consecutive weekends for three semesters. Logistic regression compared students who only reported drinking to student drinkers who used marijuana, nicotine, or all three substances on likelihood to DUI and RWID. Multilevel logistic models assessed the associations of varied combinations of substances with the daily likelihood of DUI and RWID.

RESULTS

Compared to students who only used alcohol, students who also reported marijuana use were more likely to DUI (OR = 5.44), and students who reported use of alcohol, nicotine and marijuana more likely to DUI (OR = 10.33) and RWID (OR = 10.22). Compared to occasions when only alcohol was used, DUI was more likely on marijuana only occasions (OR = 9.08), and RWID was more likely on alcohol and marijuana occasions (OR = 3.86). However, confidence intervals were wide for effects.

DISCUSSION

Students reporting use of all 3 substances had higher overall risk of DUI and RWID indicating prevention efforts for DUI and RWID should include all substances. Implications for prevention and intervention strategies at the individual and environmental level are discussed.

Same-day use of cigarettes, alcohol, and cannabis among sexual minority and heterosexual young adult smokers

OBJECTIVE

Sexual minority (SM) young adults have higher rates of substance use than heterosexuals, but little is known about daily use of multiple substances, which confer numerous health risks for this population. Using daily diary data from a smartphone-based study, we examined the associations between sexual identity (i.e., SM vs. heterosexual) and patterns of same-day multiple substance use (i.e., cigarettes and alcohol, cigarettes and cannabis, alcohol and cannabis, and all 3 substances).

METHOD

Young adult smokers (N = 147, aged 18-26, 51.7% female, 41.5% SM, 40.8% White) reported consecutive daily assessments on substance use over 30 days. We used generalized estimating equations to examine associations between sexual identity and patterns of same-day multiple substance use, controlling for demographic factors and psychological distress.

RESULTS

Of 2,891 daily assessments, 16.7% reported same-day use of cigarettes and alcohol, 18.1% cigarettes and cannabis, 1.5% alcohol and cannabis, and 15.0% use of all 3 substances. SM participants (vs. heterosexuals) had significantly greater odds of reporting days with use of cigarettes and cannabis [Adjusted Odds Ratio (AOR) = 2.05, 95% Confidence Interval (CI) [1.04, 4.01]] and use of all three substances (AOR = 2.79, 95% CI [1.51, 5.14]) than days with single substance use or no use.

CONCLUSIONS

These findings warrant tailored interventions addressing multiple substance use among SM young adults and temporally accurate measures of multiple substance use patterns. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Perceived reward from using cigarettes with alcohol or cannabis and concurrent use: A smartphone-based daily diary study

INTRODUCTION

Smoking cigarettes under the influence of alcohol or cannabis is associated with perceived pleasure. However, it is unclear whether these changes in perceived reward impact the extent of concurrent use of cigarettes with alcohol or cannabis. The current study investigated if self-reported changes in perceived reward from concurrent use of cigarettes with alcohol or cannabis are related to the extent of concurrent use in real-world contexts using a smartphone-based Ecological Momentary Assessment (EMA) study.

METHODS

The sample included 126 diverse young adult smokers in the San Francisco Bay Area who reported current alcohol or cannabis use at baseline (M = 22.8 years, 50.8% male, 40.5% sexual minority, 39.7% Non-Hispanic White). Participants completed an online baseline survey and 30 days of smartphone-based daily EMA surveys of cigarette, alcohol, and cannabis use. The baseline assessed self-reported changes in perceived pleasure of smoking cigarettes while using alcohol or cannabis separately. EMA surveys included detailed questions about concurrent use (i.e., the extent of smoking while using another substance) covering the previous day. A total of 2,600 daily assessments were analyzed using mixed models.

RESULTS

Higher perceived pleasure from smoking cigarettes while drinking alcohol or using cannabis at baseline were both associated with a greater extent of concurrent use of cigarettes with alcohol (b = 0.140; SE = 0.066; t = 2.1; p = .035) and cannabis (b = 0.136; SE = 0.058; t = 2.4; p = .019) on a given day.

CONCLUSIONS

Results suggest that perceived reward from concurrently using cigarettes with alcohol or cannabis is associated with the extent of concurrent use. Findings can inform tailored smoking cessation interventions.

Treatment Implications Associated with Cannabis and Tobacco Co-Use

PURPOSE OF THE REVIEW

The goal of this article is to summarize the treatment-focused literature on cannabis and tobacco co-use and the treatment implications of co-use. This review will focus on: 1) the impact of co-use on cessation outcomes, 2) compensatory use/substitution of the non-treated substance among co-users, and 3) treatment interventions to address co-use. This article will highlight the limitations to co-use captured in the literature and offer considerations and directives for co-use research and treatment moving forward.

RECENT FINDINGS

The degree to which co-use affects cessation for a single, targeted substance remains in question, as the literature is largely mixed. Cannabis treatment trials are better equipped to answer these questions given that they do not typically exclude tobacco users. While the relationship between tobacco use and poorer cannabis outcomes appears to have some evidence, the reverse relationship (cannabis use affecting tobacco outcomes) is not consistently supported.

SUMMARY

The co-use of cannabis and tobacco and its impact on single substance cessation and/or compensatory substance use during cessation is generally overlooked in treatment trials, while interventions to address both substances are rare. Capturing co-use adds burden for researchers, clinicians, and participants, but is warranted given the prevalence of co-use and a rapidly changing cannabis and tobacco regulatory environment, which may further complicate co-occurring substance use. Co-users are a heterogeneous population; trials focused on co-users, in addition to better data capture and consistent terminology, will aid in an understanding of nuanced patterns of co-use critical to inform treatment interventions.