Abstract
Background:
Cannabis use is common among people who use tobacco, however, few studies have examined route-specific cannabis use in the context of tobacco. This study provides nationally representative 2024 prevalence estimates for overall and route-specific cannabis use by tobacco use status.
Methods:
Data were from the nationally representative 2024 Health Information National Trends Survey (N = 6328). Measures included past 12-month cannabis use and route of administration (smoking; vaping; dabbing; eating/drinking (consumed); applying a lotion; 2+ routes) and current any tobacco use. Multivariable logistic regression models examined the association between current tobacco use and past 12-month route-specific cannabis use, adjusting for state-level cannabis legality, reasons for use, and sociodemographic characteristics.
Results:
An estimated 23.1% of US adults reported past 12-month cannabis use: 62.6% smoked, 57.6% consumed, 40.1% vaped, 15.2% applied lotion, and 12.4% dabbed, with over half (52.7%) endorsing >1 route of administration. Cannabis use was higher among adults who currently used tobacco products (46.0%) compared to those who did not (17.4%) (p<.001). Among those reporting past 12-month cannabis use, those who currently used tobacco (vs. did not) were more likely to smoke cannabis (73.4% vs. 55.6%, p=.001), vape cannabis (52.4% vs. 32.1%, p<.001), or use 2+ routes (60% vs 47.9%, p=.02).
Conclusions:
In 2024, nearly 1 in 2 adults who currently used tobacco reported using cannabis. Current tobacco use was significantly associated with increased likelihood of past 12-month cannabis use. Continued surveillance and research on the interplay of cannabis and tobacco use is needed to understand co-use health effects.
Keywords: cannabis use, tobacco use, route of administration, co-use
Introduction
Cannabis is one of the most widely used substances in the United States (US) (Carlini et al., 2022; SAMHSA, 2024). Among youth and adults, prevalence of any past 30-day cannabis has increased over time, from 7.59% in 2013 to 15.11% in 2022 (Mattingly et al., 2024). Expanded legal access at the state-level (i.e., medical marijuana and recreational use laws) has been associated with a growing range of administration routes, such as smoking, vaping, and consuming edibles (Borodovsky et al., 2016). Most nationally representative studies assess cannabis use using broad measures (e.g., any past 30-day use) rather than specific administration routes (Rubenstein et al., 2024). Different administration routes likely carry different health risks (e.g., combustible vs non-combustible products and respective associations with respiratory health, cardiovascular health, and cancer risk) and have important public health implications (e.g., route-specific product standards, product formulations, and regulatory practices) (Spindle et al., 2019).
Cannabis use is common among people who use tobacco products. In 2019, US nationally representative data indicated that nearly one third of current (past 30-day) tobacco users also reported current cannabis use, whereas only about 10% of non-tobacco users reported current cannabis use (Rubenstein et al., 2024). Evidence also suggests that cannabis and tobacco co-use has significantly increased over time (Lemyre et al., 2019; Strong et al., 2018; Yimer et al., 2024). Co-use has been associated with psychiatric and psychosocial problems (Peters et al., 2014), additive risk for toxic exposures (Meier & Hatsukami, 2016; Nguyen et al., 2024), and increased respiratory symptoms (Peters et al., 2014).
Although cannabis and tobacco co-use is common, few studies have examined route-specific cannabis use in the context of tobacco use. However, prior work suggests that individuals who smoke cigarettes may prefer inhalation-based cannabis routes (e.g., smoking, vaping) due to behavioral or physiological factors (Agrawal & Lynskey, 2009). However, much of the existing literature relies on non-representative samples and lacks detailed information on current cannabis products and use behaviors. As a result, nationally representative estimates of route-specific cannabis use are needed to clarify cannabis use behaviors among individuals who use tobacco and other at-risk subgroups (Gibson et al., 2026).
The 2024 Health Information National Trends Survey (HINTS 7) (hints.cancer.gov) collected nationally representative data on cannabis use among US adults, including by route of administration (e.g., smoking, vaping, dabbing, eating, drinking, applying a lotion). Using HINTS 7 data, the current study aims to: (1) estimate the prevalence of cannabis use overall and by route of administration in the US adult population, (2) compare the prevalence of overall and route-specific cannabis use by tobacco use status, and (3) assess whether differences persist after adjusting for relevant covariates.
Methods
Data were from the Health Information National Trends Survey (HINTS) 7, a nationally representative, cross-sectional postal survey of the US civilian non-institutionalized population aged 18 years and older (N = 7278). Data for HINTS 7 were collected from March to September 2024. Additional information about HINTS 7 – including sampling procedures, data collection, and weighted – can be found at http://hints.cancer.gov/. HINTS 7 was approved by the Westat Institutional Review Board (IRB).
Measures
Past 12-Month Cannabis Use.
Respondents were provided with a definition of cannabis use (see Table 1 for full text) and asked to indicate the ways in which they had used a product containing cannabis in the past 12 months: “smoking”, “vaping”, “dabbing”, “eating”, “drinking”, “applying a lotion”, “I have not used any product containing marijuana in the past 12 months”. Respondents could select multiple cannabis administration routes.
Table 1.
Past 12-month weighted prevalence estimates of cannabis use overall and by route of administration among US adults, stratified by current tobacco use and other covariates of interest, 2024 Health Information National Trends Survey.
| Administration routes endorsed by past 12-month cannabis users (n = 1287) | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Any Cannab is Product | Smoking | Vaping | Dabbing | Consuming | Lotion | 2+ Routes | ||||||||||
| Total N | % | p-value | Total n | % | p-value | % | p-value | % | p-value | % | p-value | % | p-value | % | p-value | |
| All | 63 28 | 23.1 | 1294 | 62.6 | 40.1 | 12.4 | 57.6 | 15.2 | 52.7 | |||||||
| Current Tobacco Use | <.0 01 | .00 1 | <.0 01 | .10 | .13 | .31 | .02 | |||||||||
| No | 5315 | 17.4 | 874 | 55.6 | 32.1 | 9.6 | 60.5 | 16.5 | 47.9 | |||||||
| Yes | 1013 | 46.0 | 420 | 73.4 | 52.4 | 16.7 | 53.2 | 13.2 | 60.0 | |||||||
| State level cannabis legality | <.0 01 | .46 | .03 | .99 | .30 | .49 | .07 | |||||||||
| Adult Use | 3221 | 27.4 | 772 | 63.7 | 36.8 | 12.6 | 60.7 | 13.9 | 53.0 | |||||||
| Comprehensive Medical | 1325 | 19.0 | 248 | 64.9 | 50.6 | 12.0 | 54.2 | 15.8 | 0.1 | |||||||
| CBD/Low THC Only | 1782 | 17.0 | 274 | 56.6 | 41.0 | 12.0 | 50.1 | 19.3 | 43.9 | |||||||
| Age | <.0 01 | .01 | <.0 01 | .02 | .10 | .02 | .06 | |||||||||
| 18-34 | 1043 | 30.9 | 343 | 72.7 | 53.9 | 18.1 | 49.5 | 10.5 | 60.3 | |||||||
| 35-49 | 1308 | 25.9 | 342 | 57.4 | 43.0 | 11.1 | 63.1 | 17.4 | 51.7 | |||||||
| 50-64 | 1638 | 21.4 | 312 | 58.9 | 26.1 | 10.5 | 64.3 | 14.3 | 49.0 | |||||||
| 65+ | 2335 | 12.4 | 297 | 54.4 | 21.3 | - | 53.6 | 25.2 | 40.5 | |||||||
| Sex | .49 | .12 | .65 | .27 | .42 | .16 | .58 | |||||||||
| Female | 3791 | 22.4 | 767 | 58.4 | 39.0 | 14.5 | 60.1 | 17.4 | 54.3 | |||||||
| Male | 2537 | 23.7 | 527 | 66.4 | 41.0 | 10.5 | 55.4 | 13.2 | 51.2 | |||||||
| Race/Ethnicity | .43 | .01 | <.0 01 | <.0 01 | .20 | .13 | .15 | |||||||||
| NH White | 3510 | 24.0 | 738 | 59.5 | 42.1 | 12.8 | 59.5 | 13.7 | 52.6 | |||||||
| NH Black | 970 | 24.0 | 195 | 70.9 | 18.2 | - | 46.6 | 16.5 | 41.8 | |||||||
| NH Other | 589 | 19.0 | 111 | 79.4 | 37.4 | - | 53.3 | - | 54.2 | |||||||
| Hispanic | 1259 | 21.4 | 250 | 59.9 | 50.5 | 20.9 | 60.7 | 23.0 | 0.0 | |||||||
| Education | .14 | .02 | .19 | .06 | <.0 01 | .36 | .48 | |||||||||
| HS or Less | 1395 | 21.4 | 253 | 68.9 | 44.6 | 17.6 | 42.9 | 17.5 | 48.6 | |||||||
| Some College | 1850 | 25.7 | 415 | 66.1 | 41.6 | 14.4 | 55.9 | 12.1 | 55.8 | |||||||
| Four Year Degree or More | 3083 | 21.4 | 626 | 53.2 | 34.4 | 5.7 | 71.1 | 17.6 | 51.3 | |||||||
| Income Feelings | <.0 01 | .03 | .24 | .05 | .17 | .28 | .05 | |||||||||
| Comfortable | 2369 | 18.9 | 394 | 54.7 | 33.0 | 8.0 | 62.8 | 17.5 | 43.2 | |||||||
| Getting by | 2383 | 22.9 | 470 | 62.3 | 41.4 | 9.3 | 59.3 | 12.1 | 56.7 | |||||||
| Difficult | 1576 | 29.0 | 430 | 69.8 | 44.7 | 19.6 | 51.3 | 16.7 | 56.4 | |||||||
| Reasons for Cannabis Use | <.0 01 | .62 | .01 | .11 | <.0 01 | <.0 01 | ||||||||||
| Recreational only | N/A | 569 | 65.8 | 39.1 | 7.1 | 56.4 | 7.2 | 49.4 | ||||||||
| Medical only | N/A | 293 | 29.9 | 36.9 | 9.5 | 49.7 | 31.7 | 35.0 | ||||||||
| Both recreational and medical | N/A | 432 | 77.3 | 43.4 | 21.9 | 64.2 | 17.3 | 67.9 | ||||||||
Current Tobacco Use.
Respondents were asked whether they now used e-cigarettes, cigars, hookah, smokeless tobacco, nicotine pouches, heated tobacco products, and/or modified risk tobacco products. Those who endorsed using at least one tobacco product were classified as currently using tobacco. Respondents who had smoked at least 100 cigarettes in their life and now used cigarettes every day or some days were also classified as currently using tobacco. Due to the small sample sizes (N<30), we were unable to examine specific tobacco products and instead assessed overall current tobacco use.
Sociodemographic characteristics.
Sociodemographic characteristics included age (18-34, 35-49, 50-64, 65+), sex (female, male), race/ethnicity (Non-Hispanic [NH] White, NH Black, NH Other, Hispanic), education (high school degree or less, some college, four-year degree or more), and income feelings which was perceived household income adequacy (comfortable, getting by, difficult). .
Cannabis Legality.
Using information from the National Conference of State Legislatures (NCSL) (NCSL, 2025), respondents’ states of residence were categorized as having (a) recreational and medical cannabis programs, in which both adult-use and medical cannabis were legally available through regulated state programs, (b) comprehensive medical cannabis programs, in which only a regulated medical cannabis program was in place, or (c) no public cannabis access programs or CBD/low-THC-only medical programs at the time of HINTS 7 data collection.
Reasons for Past 12-Month Cannabis Use.
Respondents who endorsed using cannabis in the past 12-months were asked whether their cannabis use was for medical, recreational, or both medical and recreational reasons.
Data Analyses
Weighted bivariate analyses using Wald χ2 tests were conducted to estimate the national prevalence of past 12-month cannabis use among US adults aged 18 years or older, both overall and stratified by current tobacco use, state-level cannabis legality, and sociodemographic characteristics. Among respondents who reported past 12-month cannabis use, the same approach was used to estimate the weighted prevalence of each route of cannabis administration (smoking, vaping, dabbing, eating, drinking, lotion, or use of ≥ 2 routes).
Weighted multivariable logistic regression models were conducted to examine the association between current tobacco use and past 12-month cannabis use, adjusting for state-level cannabis legality, reasons for cannabis use and sociodemographic characteristics. Among respondents who reported past 12-month cannabis use, the same approach was used to examine associations between current tobacco use and each route of cannabis administration (smoking, vaping, dabbing, eating, drinking, lotion, or use of ≥2 routes). Complete case analysis with listwise deletion was used, resulting in a final analytic sample of N= 6328. Analyses were conducted in R version 4.4.1. R’s “survey” package incorporated sample and jackknife replicate weights to account for HINTS’ complex sampling design and yield representative population estimates. Statistical significance was defined as p < .05 (two-tailed).
Results
In 2024, 23.1% of US adults reported using cannabis within the past 12 months. Among individuals reporting past 12-month cannabis use, 62.6% endorsed smoking cannabis, 57.6% eating or drinking cannabis, 40.1.% vaping cannabis, 15.2% applying cannabis topically as a lotion, and 12.4% dabbing cannabis. Over half (52.7%) of those who reported past 12-month cannabis use reported more than one route of cannabis administration.
Table 1 presents the weighted prevalence of past 12-month cannabis use in the overall sample, as well as the distribution of reported routes of cannabis administration among individuals who reported past 12-month cannabis use, stratified by current tobacco use and other covariates of interest. Past 12-month cannabis use was more prevalent among individuals who currently used tobacco (46%) compared to those who did not (17.4%). The prevalence was also higher in states with legalized recreational cannabis (27.4%). Among individuals who reported past 12-month cannabis use, smoking cannabis was the most common route of administration among those who currently used tobacco (73.4%), whereas consuming (i.e., eating or drinking) cannabis was the most common route among those who did not (60.5%).
Table 2 presents results from the weighted multivariable logistic regression models examining associations of current tobacco use with route of cannabis administration among individuals reporting past 12-month cannabis use. Those who currently used tobacco had higher odds of smoking (adjusted odds ratio [aOR] = 1.88; 95% CI: [1.07, 3.30]; p = .03) and vaping (aOR = 2.18; 95% CI: [1.30, 3.64]; p = .004) cannabis compared with those who did not currently use tobacco, after adjusting for covariates. Individuals who reported past 12-month cannabis use and currently used tobacco also had marginally higher odds of reporting 2+ cannabis administration routes (aOR = 1.64; 95% CI: [1.00, 2.69]; p = .052) compared with those who did not currently use tobacco. No significant differences by tobacco use status were observed for dabbing, oral consumption (eating or drinking), or topical application (ps > .52).
Table 2.
Associations of current tobacco use and route of cannabis administration among US adults reporting past 12-month cannabis use, 2024 Health Information National Trends Survey (N=6328).
| Smoking | Vaping | Dabbing | Consuming | Lotion | 2+ | |
|---|---|---|---|---|---|---|
| aOR (95% CI) p-value | ||||||
| Current Tobacco Use | ||||||
| No | Ref | Ref | Ref | Ref | Ref | Ref |
| Yes | 1.88 (1.07-3.30) .03 | 2.18 (1.30-3.64) .004 | 1.36 (0.51-3.63) .52 | 0.94 (0.59-1.48) .77 | 0.97 (0.57-1.66) .91 | 1.64 (1.00-2.69) .052 |
| State level cannabis legality | ||||||
| Recreational Use | Ref | Ref | Ref | Ref | Ref | Ref |
| Comprehensive Medical | 1.37 (0.74-2.54) .31 | 2.47 (1.61-3.78) <.001 | 1.45 (0.29-7.22) 0.64 | 0.76 (0.39-1.51) .43 | 1.00 (0.54-1.85) .995 | 1.65 (1.05-2.58) .03 |
| CBD/Low THC Only | 0.79 (0.46-1.31) 0.33 | 1.17 (0.74-2.15) .61 | 0.90 (0.33-2.47) .84 | 0.64 (0.37-1.10) .10 | 1.35 (0.65-2.82) .41 | 0.73 (0.45-1.20) .21 |
| Age | ||||||
| 18-34 | Ref | Ref | Ref | Ref | Ref | Ref |
| 35-49 | 0.53 (0.27-1.03) .06 | 0.67 (0.38-1.19) .17 | 0.60 (0.17-2.06) .40 | 1.75 (0.99-3.11) .06 | 1.92 (0.93-3.93) .08 | 0.71 (0.40-1.25) .23 |
| 50-64 | 0.69 (0.36-1.34) .26 | 0.26 (0.14-0.51) <.001 | 0.56 (0.17-1.79) .32 | 2.10 (1.04-4.23) .04 | 1.50 (0.70-3.22) .28 | 0.71 (0.38-1.35) .29 |
| 65+ | 0.75 (0.34-1.64) .46 | 0.20 (0.10-0.41) <.001 | 0.12 (0.02-0.63) .01 | 1.31 (0.67-2.55) .42 | 2.76 (1.21-6.28) .02 | 0.55 (0.26-1.15) .11 |
| Sex | ||||||
| Female | Ref | Ref | Ref | Ref | Ref | Ref |
| Male | 1.45 (0.90-2.36) .12 | 1.19 (0.72-1.98) .48 | 0.81 (0.32-2.07) .66 | 0.71 (0.41-1.23) .22 | 0.85 (0.48-1.52) .58 | 0.86 (0.51-1.47) .58 |
| Race/Ethnicity | ||||||
| NH White | Ref | Ref | Ref | Ref | Ref | Ref |
| NH Black | 1.35 (0.63-2.89) 0.43 | 0.18 (0.09-0.36) <.001 | 0.08 (0.02-0.32) <.001 | 0.70 (0.42-1.16) .16 | 1.53 (0.78-3.02) .21 | 0.52 (0.29-0.93) .03 |
| NH Other | 1.99 (1.08-3.67) .04 | 0.55 (0.24-1.25) .15 | 0.31 (0.06-1.66) .16 | 0.86 (0.34-2.17) .74 | 1.05 (0.44-2.51) .92 | 0.84 (0.33-2.15) .71 |
| Hispanic | 0.93 (0.43-2.01) 0.84 | 0.98 (0.50-1.92) .95 | 1.51 (0.59-3.85) .38 | 1.57 (0.85-2.90) .14 | 2.43 (1.29-4.55) .007 | 1.41 (0.67-2.95) .35 |
| Education | ||||||
| HS or Less | Ref | Ref | Ref | Ref | Ref | Ref |
| Some College | 0.86 (0.40-1.85) .70 | 1.08 (0.64-1.85) .76 | 0.87 (0.34-2.20) .76 | 1.47 (0.80-2.68) .20 | 0.67 (0.28-1.59) .35 | 1.44 (0.78-2.68) .24 |
| Four Year Degree or More | 0.52 (0.24-1.14) .10 | 0.67 (0.36-1.23) .19 | 0.33 (0.10-1.08) .07 | 3.13 (1.62-6.04) .001 | 1.40 (0.55-3.55) .47 | 1.38 (0.70-2.72) .34 |
| Income Feelings | ||||||
| Comfortable | Ref | Ref | Ref | Ref | Ref | Ref |
| Getting by | 1.02 (0.60-1.73) 0.94 | 1.11 (0.57-2.19) .75 | 0.60 (0.18-1.99) .40 | 0.87 (0.55-1.37) .53 | 0.65 (0.33-1.25) .18 | 1.34 (0.76-2.36) .30 |
| Difficult | 1.37 (0.80-2.33) .24 | 1.07 (0.55-2.11) .83 | 1.26 (0.41-3.93) .68 | 0.77 (0.42-1.40) .38 | 0.91 (0.45-1.82) .78 | 1.32 (0.80-2.19) .27 |
| Reasons for Cannabis Use | ||||||
| Medical only | Ref | Ref | Ref | Ref | Ref | Ref |
| Recreational only | 4.91 (2.48-9.73) <.001 | 0.99 (0.50-1.94) .97 | 0.93 (0.22-3.98) .92 | 1.31 (0.66-2.60) .43 | 0.18 (0.09-0.36) <.001 | 1.83 (0.95-3.52) .07 |
| Both recreational and medical | 8.36 (4.28-16.36) <.001 | 1.19 (0.63-2.22) .58 | 3.89 (1.76-9.75) .03 | 2.13 (1.11-4.06) .02 | 0.54 (0.26-1.01) .09 | 3.95 (2.15-7.26) <.001 |
Discussion
This study provides 2024 nationally representative estimates of route-specific cannabis use among US adults. Smoking and oral consumption were the most common routes of cannabis administration, and more than half of past 12-month cannabis users reported using multiple administration routes. As the cannabis market has diversified in recent years, this study extends the existing literature by characterizing specific routes of administration, including more novel routes such as dabbing and topicals, rather than relying on measures of “any use” within a given time frame. As different administration routes may confer distinct health risks (e.g., respiratory risks associated with inhalation), more nuanced assessment of route-specific use is critical for understanding the etiology of various cannabis use outcomes, particularly in longitudinal studies, and for supporting surveillance, prevention, and treatment efforts.
Findings from this study highlight that current tobacco use is associated with increased likelihood of past 12- month cannabis use, even after controlling for sociodemographic characteristics, reasons for use, and legality. Moreover, routes of administration did differ by tobacco use status, with a larger proportion of people who used tobacco smoking and vaping cannabis than people who did not use tobacco, in line with previous hypotheses (Agrawal & Lynskey, 2009). Alternatively, the most prevalent route of cannabis use among non-tobacco users was consuming cannabis (i.e., eating, drinking). This may reflect greater behavioral familiarity or social acceptability of inhaled routes among people who use tobacco, although our tobacco use measure encompassed more than just combustible/vaped tobacco products. Inhaled routes carry respiratory risks, which are heightened among combustible tobacco users (Peters, 2013). Co-use may also negatively impact cessation efforts, making cessation more difficult (Nguyen et al., 2024). Interestingly, tobacco use was marginally associated with use of cannabis via multiple administration routes, which may reflect a higher intensity of cannabis use (e.g., higher frequency, heavier use). This polysubstance use pattern may be associated with increased risk of both tobacco and cannabis dependence (Nguyen et al., 2024). Route-specific information may help inform tailored cessation strategies for dual users.
While this study expands the existing literature by reporting recent nationally representative estimates and assessment of cannabis administration routes, the findings should be interpreted in light of several limitations. HINTS is a cross-sectional, self-administered survey of US adults, thus, causality cannot be determined. There are also some limitations with the assessments available. For example, while HINTS measures past 12-month cannabis, this does not necessarily indicate current use, nor does it capture frequency, quantity, or potency of cannabis use. Moreover, the NCSL classification did not include legalization status of hemp-derived cannabinoids which may be an important contributor of cannabis use or co-use. Future studies with larger samples of tobacco users may be able to examine whether routes of cannabis administration differ across types of tobacco use. Future studies may also be able to examine patterns of co-use, such as whether individuals are using cannabis and tobacco sequentially or in tandem (e.g., blunts).
This study provides timely data as the cannabis landscape continues to evolve across the US. Findings show a high prevalence of cannabis use, especially among tobacco users. Routes of administration vary widely between tobacco and non-tobacco users.
Supplementary Material
Highlights.
Cannabis use was more prevalent among tobacco users vs. non-tobacco users.
Smoking cannabis was the most common administration route among tobacco users.
Consuming cannabis was the most common administration route among non-tobacco users.
Routes of administration vary widely between tobacco and non-tobacco users.
Footnotes
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Declaration of Interest
The authors declare no known competing interests related to this work.
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