Individual differences in legal and illicit cannabis purchasing behaviour in British Columbia, Canada: Findings from a 2021 cross-sectional survey.

BACKGROUND: Despite thousands of licensed cannabis retail stores operating across Canada, there remains a significant illicit cannabis market. Some cannabis users continue to buy cannabis from dealers, illicit stores, and/or illicit online retailers. METHODS: Data are from the 2021 British Columbia Cannabis Use Survey. Respondents (n = 8473) were 19 years or older, lived in British Columbia at the time of the survey, and reported using cannabis in the past 12 months. RESULTS: Buying cannabis from all types of illicit sources was more common among younger cannabis users, those who use cannabis more frequently and started using cannabis before the age of 17 (vs. 19 or older), and among those who co-use cannabis with other drugs. Specifically, buying cannabis from a dealer was more common among men, those with lower educational attainment, and those who seek the lowest prices when buying cannabis. In contrast, those using cannabis for medical (vs. non-medical) purposes were more likely to report getting cannabis from illicit retail stores, while buying cannabis from illicit websites was more common among people who use edible cannabis products. CONCLUSION: Consistent with other studies, younger and more frequent cannabis users were more likely to report buying cannabis from illicit sources. However, these findings suggest there is significant heterogeneity among those who buy cannabis from different types of illicit sources, which should be carefully considered when developing policies and strategies aimed at encouraging consumers to transition to legal sources.

Visibilización de las estrategias de rebranding y captura corporativa de la salud pública por la industria del cannabis / Visibility of rebranding and corporate capture strategies of public health by the cannabis industry

Cuando las políticas afectan a los determinantes comerciales de la salud, como el alcohol, el tabaco y el cannabis se conoce como captura corporativa de la salud pública. El objetivo del estudio fue visibilizar las estrategias promotoras del cultivo, consumo y regulación del cannabis orientadas hacia una regulación conveniente para la industria, en detrimento de la salud pública. Se siguió un diseño exploratorio cualitativo utilizando un muestro intencional a partir de los diversos canales de información utilizados por la industria del cannabis. Las estrategias de rebranding y captura corporativa halladas se fundamentan en: a) argumentos de desarrollo económico en los que justificar su expansión y una regulación laxa; b) fomento de una imagen positiva del cannabis asociando su consumo a fines de salud y bienestar; c) fomento de una imagen social más aceptable del consumidor, del autocultivador e, incluso, del vendedor; d) la captación y fidelización de consumidores a través de productos derivados del cine, la televisión o los videojuegos, y de manera especial a través de influencers; e) los regalos publicitarios y de patrocinio de eventos dirigidos al “tarjet” de los potenciales consumidores; f) la difusión de fake news que sugieren que el cannabis cura enfermedades; y, g) procesos distorsionadores que afectan a la investigación sobre el cannabis, cuando la financiación proviene de la industria del cannabis. Estos hallazgos ponen de manifiesto las acciones de captura corporativa de la industria del cannabis, orientadas a bloquear o retrasar lasmedidas de salud pública que son contrarias a sus intereses económicos (AU)

When policies affect commercial determinants of health, such as alcohol, tobacco and cannabis, it is known as corporate capture of public health. The aim of the study was to make visible the strategies promoting cannabis cultivation, consumption and regulation oriented towards industry-friendly regulation, to the detriment of public health. An exploratory qualitative design was followed using a purposive sample from the various information channels used by the cannabis industry. The rebranding and corporate capture strategies found are based on: (a) economic development arguments to justify its expansion and lax regulation; (b) promotion of a positive image of cannabis by associating its use with health and wellbeing purposes; (c) promotion of a more acceptable social image of the consumer, the self-cultivator and even the seller; (d) consumer recruitment and loyalty through products derived from film, television or video games, and especially through influencers; e) advertising and event sponsorship gifts aimed at the “tarjet” of potential consumers; f) the dissemination of fake news suggesting that cannabis cures diseases; and, g) distorting processes affecting cannabis research, when funding comes from the cannabis industry. These findings highlight the cannabis industry’s corporate capture actions aimed at blocking or delaying public health measures that are contrary to its economic interests. (AU)

Does cannabis complement or substitute alcohol consumption? A systematic review of human and animal studies.

BACKGROUND: Whether alcohol and cannabis complement or substitute each other has been studied for over two decades. In the changing cannabis policy landscape, debates are moving rapidly and spill-over effects on other substances are of interest. AIMS: update and extend a previous systematic review, by: (a) identifying new human behavioural studies reporting on substitution and/or complementarity of alcohol and cannabis, and (b) additionally including animal studies. METHODS: We replicated the search strategy of an earlier systematic review, supplemented with a new search for animal studies. Search results were crossed checked against the earlier review and reference lists were hand searched. Findings were synthesised using a narrative synthesis. RESULTS: Sixty-five articles were included (64 in humans, one in animals). We synthesised findings into categories: patterns of use, substitution practices, economic relationship, substance use disorders, policy evaluation, others and animal studies. Overall, 30 studies found evidence for substitution, 17 for complementarity, 14 did not find evidence for either, and four found evidence for both. CONCLUSIONS: Overall, the evidence regarding complementarity and substitution of cannabis and alcohol is mixed. We identified stronger support for substitution than complementarity, though evidence indicates different effects in different populations and to some extent across different study designs. The quality of studies varied and few were designed specifically to address this question. Dedicated high-quality research is warranted.

Cannabis knowledge and implications for health: Considerations regarding the legalization of non-medical cannabis.

Cannabis contains over a hundred of different cannabinoids, of which Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the most well studied. The use of high-potency cannabis, containing high concentrations of THC and low concentrations of CBD, has been linked to adverse health outcomes, particularly for adolescents and young adults. Recently, an increase in cannabis potency has been observed in jurisdictions that legalized the sale of cannabis for non-medical purposes. Moreover, an increase of cannabis use and cannabis-related emergency treatment have also been observed in these jurisdictions. At the same time, risk perception regarding cannabis use has decreased in these populations. Trivializing language and an increased appearance of commercial cannabis in the public space may lead to a generalized underestimation of the risks of cannabis use. New regulation models principally focus on the creation of a legal cannabis market economy, the diversion of profits from illegal markets, and the reduction of costs associated with prohibition. However, an approach that specifically focuses on the rights to the health and safety of the individual should be considered in order to reduce the risks associated with cannabis legalization. Such an approach should promote and protect individual and social health and safety, establish a strict quality control of legal cannabis products regulated according to THC and CBD content, and eliminate all sorts of incentives to use, thus providing a more consistent, sustainable, and ethical framework for the legalization of non-medical cannabis use.

Evaluating the co-use of opioids and cannabis for pain among current users using hypothetical purchase tasks.

BACKGROUND: Cannabinoids may potentiate opioid analgesia and therefore could be used to reduce reliance on opioids for analgesia. AIMS: The current study evaluated whether the concurrent availability of cannabis influences opioid consumption using a behavioral economic demand framework. METHODS: An online survey assessed cannabis and opioid use frequency and dependence measures, pain severity, and demand for both cannabis and opioids alone and when concurrently available using hypothetical purchase tasks. Adults reporting current use of opioids for pain management and past 30-day cannabis exposure (N=155) completed two hypothetical purchase tasks in which only grams of cannabis or units of participants' index opioids were available for purchase, and two hypothetical tasks in which both were concurrently available and the price of one drug increased whereas the other was kept constant. Paired-sample t-tests compared the demand of each drug alone with when it was available concurrently with an alternative. RESULTS: Demand intensity was significantly reduced and demand elasticity was significantly increased for both cannabis and opioids when the alternate commodity was available, although the reductions in cannabis consumption were more pronounced than they were for opioid consumption in the presence of the alternate commodity. CONCLUSIONS: These data provide behavioral economic evidence that cannabis access may modestly reduce demand for opioids in persons who have pain. Additional clinical studies that evaluate the analgesic effects of cannabis and cannabis-opioid effects on pain are warranted.

Assessing Cannabis Demand: A Comprehensive Review of the Marijuana Purchase Task.

The marijuana purchase task (MPT) is a behavioral economic measure of individualized cannabis value (i.e., demand). The MPT follows purchase tasks for other substances (e.g., alcohol, tobacco), though presents with unique caveats due to its mixed illicit status, non-uniform units of purchase and use, and substantial within substance variability in strain, potency, and quality. As the regulatory climate surrounding purchase and use of cannabis continues to evolve in the USA and globally, rigorous assessment of cannabis use and value are of the utmost importance. This study represents the first comprehensive review of investigations utilizing the MPT. Searches through PubMed and Web of Science databases by two independent coders identified 15 empirical articles referencing the use of an MPT and were published through the year 2019. Articles were coded for demographic and procedural characteristics, structural characteristics of the MPT itself, data analytic characteristics, and relationships with cannabis-related outcomes. Rigorous assessment of demand for cannabis is essential with respect to the broad public health issues surrounding cannabis legalization. We have synthesized the research presented herein and comment on vital considerations for subsequent MPT work, including recommendations for a unified approach to using the MPT in subsequent research.

The Grassroots of Grass: Cannabis Legalization Ballot Initiative Campaign Contributions and Outcomes, 2004-2016.

CONTEXT: As of November 2018, medical cannabis was legal in 33 US states and recreational cannabis in 10, mostly enacted via ballot initiative. METHODS: We identified 32 cannabis legalization initiatives from 2004 to 2016 and obtained campaign contribution and state political and demographic data. After exploratory analyses of 15 potential independent variables, we quantified effects of 4 factors (initiative year, voter turnout, population born before 1946, advocate funding advantage) on voter support and likelihood of passage. FINDINGS: A small number of campaign contributors dominated both sides of the issue, with little involvement by health advocates. Time and turnout, not money, were the factors most associated with electoral outcomes, consistent with increases in public opinion favoring cannabis legalization over time. Year, turnout, and population age were associated with voter support, while year, turnout, and advocate funding advantage were associated with likelihood of passage. When adjusting for an anomalous result, initiative year was the only variable that remained significantly associated with odds of passage, with a 1-year increase in initiative date associated with 2.02 times higher odds of passage (p < .01). CONCLUSION: These results underscore the importance of health advocate participation in developing cannabis legalization frameworks.

Government monopoly as an instrument for public health and welfare: Lessons for cannabis from experience with alcohol monopolies.

BACKGROUND: Government monopolies of markets in hazardous but attractive substances and activities have a long history, though prior to the late 19th century often motivated more by revenue needs than by public health and welfare. METHODS: A narrative review considering lessons from alcohol for monopolization of all or part of legal markets in cannabis as a strategy for public health and welfare. RESULTS: A monopoly can constrain levels of use and harm from use through such mechanisms as price, limits on times and places of availability, and effective implementation of restrictions on who can purchase, and less directly by replacing private interests who would promote sales and press for greater availability, and as a potential test-bed for new policies. But such monopolies can also push in the opposite direction, particularly if revenue becomes the prime consideration. Drawing on the alcohol experience in recent decades, the paper discusses issues relevant to cannabis legalization in monopolization of different market levels and segments - production, wholesale, import, retail for off-site and for on-site use - and choices about the structuring and governance of monopolies and their organizational location in government, from the perspective of maximizing public health and welfare interests. CONCLUSION: While the historical record is mixed for government monopolies of attractive but hazardous commodities, experience with alcohol in recent decades shows that for public health and welfare public monopolization is generally a preferable option.

Using recreational cannabis to treat insomnia: Evidence from over-the-counter sleep aid sales in Colorado.

This study seeks to understand whether people substitute between recreational cannabis and conventional over-the-counter (OTC) sleep medications. UPC-level grocery store scanner data in a multivariable panel regression design were used to compare the change in the monthly market share of sleep aids with varying dispensary-based recreational cannabis access (existence, sales, and count) in Colorado counties between 12/2013 and 12/2014. We measured annually-differenced market shares for sleep aids as a portion of the overall OTC medication market, thus accounting for store-level demand shifts in OTC medication markets and seasonality, and used the monthly changes in stores' sleep aid market share to control for short-term trends. Relative to the overall OTC medication market, sleep aid market shares were growing prior to recreational cannabis availability. The trend reverses (a 236% decrease) with dispensary entry (-0.33 percentage points, 95% CI -0.43 to -0.24, p < 0.01) from a mean market share growth of 0.14 ±â€¯0.97. The magnitude of the market share decline increases as more dispensaries enter a county and with higher county-level cannabis sales. The negative associations are driven by diphenhydramine- and doxylamine-based sleep aids rather than herbal sleep aids and melatonin. These findings support survey evidence that many individuals use cannabis to treat insomnia, although sleep disturbances are not a specific qualifying condition under any U.S. state-level medical cannabis law. Investigations designed to measure the relative effectiveness and side effect profiles of conventional OTC sleep aids and cannabis-based products are urgently needed to improve treatment of sleep disturbances while minimizing potentially serious negative side effects.

Uruguayan Cannabis Social Clubs: From activism to dispensaries?

BACKGROUND: In 2013 Uruguay regulated three models for the supply of cannabis for recreational use (Law 19.172), including Cannabis Social Clubs (CSCs). According to the Cannabis Regulation and Control Institute, 110 CSCs are active at the time of writing. OBJECTIVES: This paper has a twofold goal. Firstly, it aims to take stock of how the CSC model has continued to be implemented in practice, drawing on the first-hand accounts of those involved in its management. Secondly, our analysis seeks to contribute to the understanding of the CSC model by considering the different variants of the model that have emerged in Uruguay. METHODOLOGY: Our analysis draws on qualitative research conducted in Uruguay between June and October of 2018. We conducted 15 semi-structured and face-to-face interviews with representatives of registered Uruguayan CSCs and with 13 other stakeholders. RESULTS/CONCLUSIONS: CSCs' role as cannabis suppliers is perceived positively in terms of the type of cannabis produced and the means of distribution. We found that truly social CSCs co-exist with, and may be losing ground to, quasi-dispensary clubs. A number of factors may have contributed to this, including the Uruguayan regulatory framework, institutional context, and disengagement of members and/or CSC managers. This raises potential new challenges as to the contribution of the CSC model from a harm reduction perspective.

Triangulating web & general population surveys: Do results match legal cannabis market sales?

BACKGROUND: This paper combines complementary attributes of web and general population surveys to estimate cannabis consumption and spending in Washington State. It compares those estimates to legal sales recorded by the state's seed-to-sale tracking system, and thus exploits a rare opportunity to contrast two independent estimates for the same cannabis market. This sheds light on the question of whether nontrivial amounts of black market sales continue even after a state allows licensed production and sale. METHODS: Prevalence of past-month use is estimated from the 2015/16 U.S. National Survey on Drug Use and Health, adjusted for under-reporting. Estimates of consumption and spending per user broken down by age, gender, and frequency of use are developed from RAND's 2013 survey of cannabis users in Washington State. Supply side estimates come from the Washington State Liquor and Cannabis Board's seed-to-sale tracking system. They are expressed in terms of spending, equivalent-weight of flowers, and THC, with THC for edibles imputed using a machine learning technique called random forests. RESULTS: For the period July 1, 2016 to June 30, 2017, Washington's seed-to-sale data record sales from licensed cannabis stores of $1.17B and across all products an amount of THC that is equivalent to roughly 120-150 MT of flower. Survey responses suggest that amounts spent and quantities consumed are larger than that, perhaps on the order of $1.66B and over 200 MT, respectively. CONCLUSION: A perfect match is not expected because of sales to tourists, residual black market activity, production for medical purposes, and diversion across state lines. Nonetheless, the results suggest that three years after state-licensed stores opened, there remained considerable consumption of cannabis supplied outside of the licensed system.

Associations between young adult marijuana outcomes and availability of medical marijuana dispensaries and storefront signage.

AIMS: We investigated associations between the density of medical marijuana dispensaries (MMDs) around young adults' homes and marijuana use outcomes. DESIGN: Secondary data analysis. SETTING: Los Angeles County, CA, USA. PARTICIPANTS: A total of 1887 participants aged 18-22 years, surveyed online in 2016-17. MEASUREMENTS: Outcomes were past-month marijuana use (number of days used, number of times each day), positive expectancies and perceived peer use. Density was measured as the total number of MMDs and number of MMDs with storefront signage indicative of marijuana sales, within 4 miles of respondents' homes. FINDINGS: Eighty-four per cent of respondents had 10 or more MMDs within 4 miles of their homes. Multiple linear regression analyses that adjusted for individual-level socio-demographic characteristics and neighborhood socio-economic status indicated that living near a higher number of MMDs was associated with greater number of days used in the past month [ß = 0.025; 95% confidence interval (CI) = 0.001, 0.049; P = 0.04] and higher positive marijuana expectancies (ß = 0.003; 95% CI = 0.001, 0.007; P = 0.04). Living near more MMDs with storefront signage had a four- to six-fold larger effect on number of times used per day and positive expectancies, respectively, compared with associations with the total MMD count. Adjusting for medical marijuana card ownership attenuated the association with number of days used in the past month and positive expectancies, and an unexpected association emerged between higher MMD density and fewer number of times used each day (ß = -0.005; 95% CI = -0.009, -0.001; P = 0.03). CONCLUSIONS: For young adults in Los Angeles County, living near more medical marijuana dispensaries (MMDs) is positively associated with more frequent use of marijuana within the past month and greater expectations of marijuana's positive benefits. MMDs with signage show stronger associations with number of times used each day and positive expectancies.

The Implementation of Marijuana Legalization in New York.

In 2018, Governor Cuomo tasked the Department of Health (DOH) with studying the anticipated impact of legalizing recreational marijuana use in New York State. DOH concluded that the positive effects of a regulated marijuana market outweighed the potential negative impact but that implementation required close monitoring of usage, education of specific populations, and regular and rigorous evaluation. In states where cannabis is legal, studies have shown associated decreases in crime rates and increases in financial resources. Conversely, accidental ingestion in children and accidents following ingestion had increased. The road ahead is fraught with challenges, especially because of the nonuniformity in federal and state laws.

Implementation and Effectiveness of an Online Responsible Vendor Training Program for Recreational Marijuana Stores in Colorado, Oregon, and Washington State.

CONTEXT: Six US states have implemented retail sales of recreational marijuana. Training in responsible sales practices has been effective in the alcohol market. An online responsible marijuana vendor (RMV) training was produced and implemented with stores in a randomized trial. PROGRAM: An online RMV training was developed through meetings with state regulators and local law enforcement personnel, curriculum standards published by the Colorado Marijuana Enforcement Division in May 2015, interviews with recreational marijuana store personnel (n = 15), and usability testing of a prototype training with store personnel (n = 19) in Colorado and Washington State. The training contained 5 modules: state laws and regulations, ID checking, health effects of marijuana, customer service practices including recognizing intoxicated patrons, and rules of the trade. IMPLEMENTATION: A randomized controlled trial testing the training enrolled a random sample of state-licensed retail recreational marijuana stores (n = 225) in Colorado, Oregon, and Washington State. In total, 125 stores were randomly assigned to receive the RMV training. A total of 420 store employees completed the online training between June 2017 and February 2018 (43.5% female, 88.4% younger than 40 years, and 74.1% non-Hispanic white). EVALUATION: Responses to posttraining surveys showed that most trainees found the training user-friendly (78.4%), were satisfied (68.8%), and would recommend it to another employee (91.1%). The training improved trainees' ability to check IDs (pretraining mean = 3.91 [SD = 1.36], posttraining mean = 4.58 [SD = 0.66], t387,388 = 8.68, P < .001) and their confidence to use the state's inventory tracking system (pretraining mean = 2.52 [SD = 0.65], posttraining mean = 2.85 [SD = 0.39], t387, 388 = 10.89, P < .001) and spot intoxicated customers (pretraining mean = 2.79 [SD = 0.41], posttraining mean = 2.94 [SD = 0.25], t387,388 = 6.87, P < .001). DISCUSSION: Online RMV training was acceptable to retail recreational marijuana personnel and potentially improved responsible sales practices. Responsible vendor training has been successful under certain conditions in the alcohol market and should be considered for the recreational marijuana market.

Recreational marijuana legalization and prescription opioids received by Medicaid enrollees.

OBJECTIVES: Medical marijuana use may substitute prescription opioid use, whereas nonmedical marijuana use may be a risk factor of prescription opioid misuse. This study examined the associations between recreational marijuana legalization and prescription opioids received by Medicaid enrollees. METHODS: State-level quarterly prescription drug utilization records for Medicaid enrollees during 2010-2017 were obtained from Medicaid State Drug Utilization Data. The primary outcome, opioid prescriptions received, was measured in three population-adjusted variables: number of opioid prescriptions, total doses of opioid prescriptions in morphine milligram equivalents, and related Medicaid spending, per quarter per 100 enrollees. Two difference-in-difference models were used to test the associations: eight states and DC that legalized recreational marijuana during the study period were first compared among themselves, then compared to six states with medical marijuana legalized before the study period. Schedule II and III opioids were analyzed separately. RESULTS: In models comparing eight states and DC, legalization was not associated with Schedule II opioid outcomes; having recreational marijuana legalization effective in 2015 was associated with reductions in number of prescriptions, total doses, and spending of Schedule III opioids by 32% (95% CI: (-49%, -15%), p = 0.003), 30% ((-55%, -4.4%), p = 0.027), and 31% ((-59%, -3.6%), p = 0.031), respectively. In models comparing eight states and DC to six states with medical marijuana legalization, recreational marijuana legalization was not associated with any opioid outcome. CONCLUSIONS: No evidence suggested that recreational marijuana legalization increased prescription opioids received by Medicaid enrollees. There was some evidence in some states for reduced Schedule III opioids following the legalization.

Price elasticity of illegal versus legal cannabis: a behavioral economic substitutability analysis.

BACKGROUND AND AIMS: The evolving legal status of cannabis world-wide necessitates evidence-based regulatory policies to minimize risks associated with cannabis misuse. A prominent concern is the impact legalization may have on the illegal cannabis market, including whether illegal cannabis will serve as a substitute for legal cannabis. Empirical data on this issue are virtually non-existent. This study used behavioral economics to investigate substitutability of legal and illegal cannabis in legalized catchment areas in the United States. DESIGN: A substitution-based marijuana purchase task assessed estimated cannabis consumption from concurrently available legal (a dispensary) and illegal (a dealer) sources. Prices of the two options were reciprocally either held constant ($10/gram) or escalated ($0-$60/gram). SETTING: US states with legalized recreational cannabis. PARTICIPANTS: Adult cannabis users who were at least 21 years old (n = 724; mean age = 34.13; 52% female; 74% Caucasian) were recruited using online crowdsourcing. MEASUREMENTS: Mean consumption values were used in demand curve modeling to generate indices of price sensitivity and elasticity. Differences in demand indices were compared using extra sums-of-squares F-tests. FINDINGS: Both legal and illegal fixed-price cannabis options had significant positive cross-price elasticities (Ps < 0.001), indicating that higher prices motivate substitution irrespective of legality. However, the presence of a legal alternative had a substantially greater effect on consumption and elasticity of illegal cannabis (∆elasticity  = 0.0019; F(1,37)  = 160, P < 0.0001) than the presence of an illegal alternative on demand for legal cannabis (∆elasticity  = 0.0002; F(1,37)  = 48, P < 0.0001), indicating asymmetric substitution. Demand for legal cannabis was significantly greater than for illegal cannabis (P < 0.0001). CONCLUSIONS: Cannabis users treat legal cannabis as a superior commodity compared with illegal cannabis and exhibit asymmetric substitutability favoring legal product. Cannabis price policies that include somewhat higher consumer costs for legal cannabis relative to contraband (but not excessively higher costs) would not be expected to incentivize and expand the illegal market.

Among whom is cigarette smoking declining in the United States? The impact of cannabis use status, 2002-2015.

OBJECTIVES: To 1) estimate changes in the prevalence of daily and non-daily cigarette smoking among current (past 30-day) daily, non-daily, and non-cannabis users in the United States (U.S.) population; 2) examine time trends in current (past 30-day) cigarette smoking in daily, non-daily, and non-cannabis users ages 12+ from 2002 to 2015. METHODS: Data collected annually from the 2002 to 2015 National Survey on Drug Use and Health (NSDUH) were employed. Linear time trends of daily and non-daily cigarette smoking were assessed using logistic regression with year as the predictor. RESULTS: In 2015, the prevalence of current (past 30-day) cigarette smoking was highest among daily (54.57%), followed by non-daily (40.17%) and non-cannabis users (15.06%). The prevalence of non-daily cigarette smoking increased among daily cannabis users from 2002 to 2015, whereas non-daily cigarette smoking declined among non-daily cannabis users and non-cannabis users from 2002 to 2015. Daily cigarette smoking declined among both cannabis users and non-users; the most rapid decline was observed among daily cannabis users, followed by non-daily and then by non-cannabis users. However, the relative magnitude of the change in prevalence of daily cigarette smoking was similar across the three cannabis groups. CONCLUSIONS: Despite ongoing declines in cigarette smoking in the U.S., non-daily cigarette smoking is increasing among current cannabis users, a growing proportion of the U.S. POPULATION: Daily and non-daily cigarette smoking continue to decline among those who do not use cannabis. Efforts to further tobacco control should consider novel co-use-oriented intervention strategies and outreach for the increasing population of cannabis users.