Progression from marijuana use to daily smoking and nicotine dependence in a national sample of U.S. adolescents
Introduction
While several epidemiologic studies have examined gender, ethnicity, peer and parental influences as predictors of regular smoking (Griesler et al., 2002, Hu et al., 2006, Kandel et al., 2004), little attention has been given to the effects of marijuana use on smoking behavior. Marijuana has seldom been considered a risk factor for smoking because of the prevailing notion that marijuana use occurs after the initial use of tobacco. As posited by the “stage theory”, use of the lower ordered substances (alcohol, cigarettes) precedes use of marijuana, which, in turn, predicts use of the harder illicit drugs (e.g. cocaine) (Fergusson et al., 2006, Kandel et al., 1992, Lessem et al., 2006). Supporting this hypothesis, Vega and Gil (2005) demonstrated in a longitudinal study that regular cigarette smokers had an increased risk (OR = 4.8, 95% CI: 3.2–7.4) of developing lifetime marijuana abuse, or dependence, as compared with abstainers (Vega and Gil, 2005).
While the “stage theory” suggests that marijuana use occurs after the initiation of tobacco smoking, substantial evidence exists that they occur concurrently, and that use of one may influence use of the other. Critics of the “stage theory” have also argued that the stages of progression may merely reflect the availability of substances, and that an underlying propensity may account for use of any one drug (Morral et al., 2002). Cross-sectional studies from the 1994 (Lai et al., 2000) and 1997 (Richter et al., 2005) National Household Survey on Drug Abuse (NHSDA) have reported that those who smoked cigarettes were over seven times more likely to use marijuana compared with non-smokers, and that marijuana users compared with non-users were over five times more likely to smoke cigarettes, respectively. The common co-occurrence of use of these substances, i.e. 74% of marijuana smokers were tobacco smokers in the 1997 NHSDA, suggests more of a reciprocal relationship rather than a relationship characterized by the transitioning from one substance to the other. A reciprocal relationship is also consistent with reports of adolescent marijuana users who stated that they would smoke cigarettes as either a substitute for marijuana when cannabis was in short supply, or as a means of counteracting the sedating effects of marijuana (Amos et al., 2004, Highet, 2004, Tullis et al., 2003).
It is plausible that a reciprocal relationship between tobacco and marijuana could contribute to the eventual development of nicotine dependence. This hypothesis was the basis of two studies which examined marijuana use as a predictor of failure in the cessation of cigarette smoking (Gourlay et al., 1994, Humfleet et al., 1999). Results from the interventions by Gourlay et al. (1994) and Humfleet et al. (1999) indicated that marijuana use in the former study, but not the latter, was negatively associated (OR = .4, 95% CI: .2–.8) with success in quitting. Ford et al. (2002) observed that among adults who smoked cigarettes, marijuana users compared with non-users at baseline had an almost two-fold greater likelihood of smoking cigarettes 13 years later (Ford et al., 2002). A more recent longitudinal study (Patton et al., 2005) reported that young Australians who used cannabis daily had over a three-fold increase in the odds of becoming nicotine dependent (OR = 3.6, 95% CI: 1.2–10).
In the present study, we examined three measures of marijuana use at wave I (lifetime use, use in the prior month, age at first use) as predictors of tobacco smoking in young adults from the National Longitudinal Study of Adolescent Health (Add Health). We hypothesized that the use of marijuana in adolescence would increase the likelihood of developing nicotine dependence (ND) and initiating daily smoking at an earlier age. This hypothesis is, in part, supported by the qualitative observation that marijuana has reinforcing effects on cigarette smoking (Amos et al., 2004, Highet, 2004). Expanding on previous research (Patton et al., 2005), censored regression was employed to account for individuals who had not passed through the greatest risk period for developing regular smoking habits.
Section snippets
Design of add health sample
Participants from the National Longitudinal Study of Adolescent Health (Add Health) were originally sampled from 132 public and private schools throughout the United States. Details about the sampling frame (type of school, census region, degree of urbanicity, percent Caucasian) have been published previously (Alexander et al., 2001). From the 132 schools, an in-school questionnaire was administered to 90,118 students between September 1994 and April 1995. A subsample of these students was then
Descriptive analyses
For descriptive purposes, participants in Table 1 and Fig. 2 were categorized into three groups of cigarette smokers: non-daily cigarette smokers who had not developed ND, daily cigarette smokers who had not developed ND, and cigarette smokers who had developed ND. Explanatory variables for frequency of cigarette smoking, age at onset of cigarette and marijuana use, and number of peer cigarette smokers were dichotomized in Table 1, but examined as continuous measures in subsequent regression
Discussion
Marijuana use in older adolescence was modestly associated with early initiation into daily cigarette smoking and the development of nicotine dependence by young adulthood. These associations were observed after having adjusted estimates for smoking levels in adolescence, age at initiation of cigarette smoking, peer and parental smoking, and other demographic risk factors. We observed inverse associations between age at first use of marijuana and nicotine dependence, results which are
Acknowledgements
We would like to thank all participants of the National Longitudinal Study of Adolescent Health. This research used data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by a grant P01-HD31921 from the National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Persons
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