Blunt and non-blunt cannabis use associated with cigarette, e-cigarette, and cigar initiation: Findings from the population assessment of tobacco and health (PATH) study

Background: Smoking cannabis using a tobacco-derived cigar shell or wrap, called blunt smoking, exposes in-dividuals to non-trivial amounts of nicotine. The extent smoking blunts impact the risk of initiating other tobacco products is not well understood. We investigated if past-year blunt smoking is related to the risk of initiating cigarettes, e-cigarettes, and cigars.Methods: We obtained data on a nationally representative, non-institutionalized, civilian cohort of US residents aged 12 years and older who had never used cigarettes, e-cigarettes, or any cigar at baseline and surveyed annually for three years from the Population Assessment of Tobacco and Health Study. We estimated the pro-portional hazard (odds) of initiating these tobacco products associated with past-year blunt smoking, non-blunt cannabis use, or neither using discrete-time survival analyses.Results: Smoking blunts increased the risk of starting cigarettes (OR = 4.5), e-cigarettes (OR = 3.7), and cigars (OR = 6.7) compared to using neither blunts nor cannabis. Non-blunt cannabis use also increased the risk of starting cigarettes (OR = 4.0) but moderately for e-cigarettes (OR = 2.8) and any cigar (OR = 2.2). Blunt use was strongly related to starting combustible tobacco (cigarettes or cigars; OR = 9.0) and any three tobacco products (OR = 10.9). Exploratory findings showed that cigarillos drove cigar results and effect modification by age, race/ ethnicity, and sex.Conclusions: People who smoke blunts risk starting cigarettes, e-cigarettes, and cigars more than those who abstain from cannabis. Blunts may contribute to tobacco initiation above cannabis alone.