Cannabis Use and Progression to Regular Tobacco Use among United States Youth and Young Adults: Evid

Chen J, Messer K, Pierce JP, Strong DR, Quach NE, Shi Y, McMenamin SB, Khin TN, Stone MD, Trinidad DR. Cannabis Use and Progression to Regular Tobacco Use among United States Youth and Young Adults: Evidence from the Population Assessment of Tobacco and Health (PATH) Study, 2017-2021
Tob Control. 2025 Oct 23:tc-2025-059634. doi: 10.1136/tc-2025-059634. Epub ahead of print. PMID: 41130906.

Background: Tobacco use among United States (US) youth and young adults has declined from historic levels, but cannabis use has not. The importance of cannabis use as a risk factor for tobacco initiation is not known.

Methods: The association between past 12-month cannabis use in 2017 (study exposure; wave 4) and new-onset regular tobacco use in 2021 (study outcome; wave 6) was examined in a prospective representative US cohort aged 12-24 years who had never regularly used tobacco. Exposed respondents were propensity score matched to unexposed controls on demographics, tobacco use history, perceived harmfulness of cigarettes, mental health symptoms and other measures.

Results: Among these US youths aged 12-17 years who used cannabis, 32.7% (95% CI: 28.9% to 36.7%) progressed to regular tobacco use in 2021, an increase of 15.6 percentage points (pp) (95% CI: 11.1 pp to 20.2 pp) compared with their matched controls. Among the young adults aged 18-24 years, 14.0% (95% CI: 11.9% to 16.5%) of cannabis users reported regular tobacco use at follow-up, an increase of 5.4 pp (95% CI: 2.6 pp to 8.2 pp) over their matched controls. The matching analysis attributed 13.0% of total new regular tobacco use in the US to cannabis (the population attributable fraction), and estimated that in the absence of cannabis, 509 800 fewer US youth and young adults would have progressed to regular tobacco use in 2021.

Conclusion: Among US youth and young adults who had never regularly used tobacco, cannabis use in 2017 was associated with a large increase in current regular tobacco use in 2021.