The aim of this study was to characterize tobacco and marijuana use among young people experiencing homelessness in a Midwest city. Findings indicate that most (85%) combustible tobacco users in our study currently used marijuana. This is consistent with another larger study of youth experiencing homelessness in LA County that found that 90% of any tobacco users were also using marijuana (10). Nationally among high school-aged youth, 53.6% of single tobacco product (cigarettes, cigars, smokeless tobacco) users and 64.5% of users of at least two tobacco products also used marijuana in the past month (26). Together, these studies suggest that co-use of marijuana is higher in youth and young adults experiencing homelessness than among the general population of young people.
The vast majority of participants had used marijuana on 100 or more occasions in their lives (72%). Although we did not measure past-month quantity of use, long-term data show that those who initiate marijuana use in adolescence and continue through young adulthood and use heavily have higher odds of negative health outcomes, such as substance or psychiatric problems, than non-users (27). We also found that 27% of our sample used marijuana daily in the past month and that daily use was associated with not smoking combustible tobacco due to negative affect, younger age of tobacco initiation, and using substances to cope with one’s housing situation. Related to affect, evidence suggests that context matters – one study of young adults found that positive affect was related to lower odds of daily marijuana use among non-college students, but that negative affect was related to lower odds of daily marijuana use among college students (28). A systematic review of marijuana use concluded that earlier age of initiation of marijuana and initiating tobacco are associated with increased risk of later marijuana dependence (29). Given that homeless smokers initiate at a younger age, development of frequent marijuana use may be more likely in this population (30). Future research should assess frequency and quantity of marijuana use in relation to tobacco use among youth experiencing homelessness over time to better understand the health risks faced by this population.
Most smokers used marijuana through a blunt, co-administering with tobacco, with 85% of the sample reporting past-month use of blunts and 70% reporting usually smoking marijuana in blunt or a spliff. Another study in LA County found that 65% of current tobacco using youth and young adults experiencing homelessness co-administered tobacco and marijuana, which was associated with more frequent product use and often being around people who co-administer (10). Among young adults, co-administering tobacco and marijuana is associated with more frequent marijuana and tobacco use, use in greater quantity, and negative consequences due to marijuana use (e.g., missed an obligation, got into trouble, etc.) compared with exclusive users of each product type and users who sequentially use the products (31). More research is needed on the context of co-use among youth experiencing homelessness to address the psychosocial factors that influence these use patterns.
Using marijuana and tobacco together has been linked to development of nicotine and marijuana dependence, which could have implications for cessation intervention design (32). We did not assess interest in quitting smoking marijuana, and there is no evidence on marijuana cessation among youth experiencing homelessness. However, studies of adults and housing-secure individuals point to the need to address use of both products in smoking cessation studies. One study of tobacco Quitline callers found that of smokers who also reported currently using marijuana, 43% were interested in quitting marijuana in addition to tobacco (33). Another study of dual tobacco and marijuana users found compensation of one product when trying to quit the other, with 50% perceiving an increase in their marijuana smoking during tobacco cessation and 62% perceiving an increase in tobacco use during marijuana cessation (34). Some studies have found reduced tobacco cessation among marijuana users (35, 36). To develop cessation interventions for youth experiencing homelessness, targeting use of both tobacco and marijuana may be necessary. A meta-analysis of interventions targeting co-users found weak evidence for an effect on marijuana cessation and no clear effect on tobacco cessation (37). More research is needed to understand the relationship between use of combustible tobacco and marijuana and cessation of one product or both, especially among young people experiencing homelessness.
Poly-tobacco use was common in our study, with 89% reporting the use of a combustible product and at least one other product. Poly-tobacco use in the general population of youth and young adults is lower. In 2013, 57.1% of youth and 65.2% of young adults used cigarettes and at least one other product in the past month (38). Across age groups in the same study, over 70% of past-month cigar smokers used at least one other tobacco product, and the predominant pattern of use was cigar and cigarette dual use (39). Although poly-tobacco use is high across all youth and young adults, with much fewer young people in the general population using tobacco compared with homeless youth, the burden of poly-tobacco use is greater among youth experiencing homelessness. Poly-tobacco use is associated with increased nicotine dependence (40), so may be necessary to address in smoking cessation interventions.
The most prevalent combination of products used in our study was two or more combustible products. In addition, combustible products (except hookah) were more frequently used than non-combustible products. This may be related to increased access due to reduced price and increased availability of cigars in particular (93% of our sample smoked cigars in the past month), which are more likely to be sold in low-income neighborhoods (41, 42). Daily combustible tobacco use (47% of the sample) was associated with smoking out of habit or boredom, having at least one child, and tending not to ignore feelings of pain or discomfort. These findings are mostly consistent with other studies. A national study of young adults found that those who had at least one child were two times as likely to have ever smoked daily than those with no children (43), likely related to added stressors, especially for those without shelter. Other studies show that young adults who are novelty-seekers and who have more unorganized leisure time are more likely to be daily smokers (43, 44), which could indicate that providing structured activities, particularly in the context of time spent at a homeless drop-in center, could reduce frequent smoking.
The differences in patterns of use of combustible and non-combustible products in this study could also be due to attitudes and beliefs about product types. Youth experiencing homelessness have different perceptions of various non-cigarette tobacco products. A study found that perceptions of EVPs were generally negative due to their cost and a perception that EVPs may be just as harmful as cigarettes (11). Smokeless tobacco was also viewed negatively, as was snus, with homeless youth having mixed opinions about whether they are more or less harmful than regular cigarettes. These misperceptions could perpetuate the use of combustible products. It should be noted that our inclusion criteria included having used a combustible tobacco product in the past week, so the primary pattern of poly-combustible use and the difference in frequency of use of these products could be explained in part by this requirement.
Brand preferences were more common for cigarettes and cigars than for smokeless tobacco and EVPs. This may be related to less frequent use of non-combustible products in our study and thus less affiliation with a brand. Newport and Black & Mild were the most popular cigarette and cigar brands, respectively. A national study of brand preferences among young adults found that while Marlboro was the most preferred brand, Newport was more preferred among Black, non-Hispanic and low-income young adults (45). In this same study, Swisher was the most preferred brand of cigar, followed by Black & Mild. The dominance of Black & Mild in our sample is somewhat surprising given that co-use of cigars with marijuana was so common, and Swishers are often the brand used to create blunts; however, Black & Mild is preferred to smoke only tobacco (46, 47). Consistent with the popularity of Newport cigarettes, most (three-quarters) cigarette smokers usually smoked menthol cigarettes. Menthol cigarettes have been marketed heavily to disadvantaged groups, including young and Black consumers (48), so exposure to such marketing in our sample is likely. About half of cigar smokers usually use a flavored product, with fruit being the most popular, followed by alcoholic drink, and candy flavors, which is consistent with these flavors’ share of the market nationally (49). Flavored use was also common among non-combustible tobacco users, with fruit flavors most popular among EVP users and menthol most popular among smokeless users, aligned with preferences in the general population of youth and young adults (50). Regulators should restrict sale and marketing of flavored tobacco use, particularly menthol in cigarettes and flavored cigars, which could make tobacco less appealing to homeless youth.
Data are available on tobacco and marijuana use prevalence among other samples of youth experiencing homelessness (10), but our study is one of the first to additionally assess flavor use, brands, and frequency of use among a sample of youth and young adults experiencing homelessness. However, there are several limitations to note. First, as our sample was a small convenience sample of youth and young adults experiencing homelessness in one drop-in center in one city, our results may not generalize to other geographic areas. Second, measures relied on self-report, so measurement error is possible. Third, another issue possibly affecting measurement is the difficulty in assessing cigars with only tobacco and blunts, which are often conflated (51). However, providing definitions in the survey questionnaire likely minimized this problem.