The Influences of Health Beliefs and Identity on Adolescent Marijuana and Tobacco Co-Use.

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The Influences of Health Beliefs and Identity on Adolescent Marijuana and Tobacco Co-Use Rebecca J. Haines-Saah, Barbara Moffat, Emily K. Jenkins and Joy L. Johnson Qual Health Res 2014 24: 946 originally published online 16 June 2014 DOI: 10.1177/1049732314539854 The online version of this article can be found at: http://qhr.sagepub.com/content/24/7/946

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QHRXXX10.1177/1049732314539854Qualitative Health ResearchHaines-Saah et al.

Article

The Influences of Health Beliefs and Identity on Adolescent Marijuana and Tobacco Co-Use

Qualitative Health Research 2014, Vol. 24(7) 946–956 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314539854 qhr.sagepub.com

Rebecca J. Haines-Saah1, Barbara Moffat1, Emily K. Jenkins1, and Joy L. Johnson1

Abstract Among youth, the co-use of marijuana and tobacco is highly prevalent, yet a considerable gap remains in the drugprevention literature pertaining to such co-use. In particular, the prevention field lacks research exploring how adolescents understand the health implications of smoking these two substances in combination. In this article, we draw on qualitative interviews with adolescents from three communities in British Columbia, Canada, and describe the health beliefs and social identities that they associated with smoking marijuana and tobacco. We argue that smoking prevention and cessation initiatives targeting adolescents must address both marijuana and tobacco. Such initiatives must also be designed to identify and address how adolescents frame the potential health harms associated with smoking these substances. Keywords adolescents / youth; research, qualitative; smoking cessation; tobacco and health Polysubstance use, or the consumption of multiple psychoactive substances, is common among adolescents, with the co-use of marijuana, tobacco, and alcohol being particularly prominent (Leatherdale, Hammond, & Ahmed, 2008; Smit, Monshouwer, & Verdurmen, 2002). In Canada, the results from the population-based Youth Smoking Survey showed that the 12-month prevalence of marijuana use was notably higher among adolescents who had tried cigarette smoking. Among adolescents in Grades 7 to 9, the prevalence of marijuana use was 83.5% for cigarette smokers; this compares to 3.9% for their non-cigarette-smoking counterparts. For those in Grades 10 to 12, it was 81.6% for cigarette smokers and 16.6% for their non-cigarette-smoking counterparts (Health Canada, 2010). Despite evidence indicating that polysubstance use is commonplace among youth, a considerable gap exists in understanding the co-use of marijuana and tobacco (Ramo, Liu, & Prochaska, 2012). In particular, research aimed at identifying how adolescents understand the health implications of smoking these two substances in combination, often mixed together, is lacking. In this article, we address this knowledge gap by describing how adolescents framed decisions about marijuana and tobacco co-use and by paying particular attention to how they evaluated the health risks associated with smoking these two substances. As part of the Teens Report on

Adolescent Cannabis Experiences Project (TRACE), based in British Columbia (BC), Canada, we explored marijuana and tobacco use patterns and health beliefs. We also explored the extent to which adolescents’ co-use practices were associated with context-based social identities or their perceptions about what it meant to be a marijuana or tobacco smoker.

Background Polysubstance use in adolescent populations is reported in many publications (Barrett, Darredeau, & Pihl, 2006; Boys & Marsden, 2003; Ellickson, Tucker, Klein, & Saner, 2004; Leatherdale et al., 2008; Smit et al., 2002). Researchers suggest a reciprocal relationship between tobacco and marijuana use (Aung, Pickworth, & Moolchan, 2004; Degenhardt et al., 2010; Mathers, Toumbourou, Catalano, Williams, & Patton, 2006; Ream, Benoit, Johnson, & Dunlap, 2008; Smith, Steward, Peled, Poon, & Saewyc, 2009), with Mathers et al. (2006) 1

University of British Columbia, Vancouver, British Columbia, Canada

Corresponding Author: Rebecca J. Haines-Saah, University of British Columbia, School of Nursing, 302-6190 Agronomy Road, Vancouver, BC V6T 1Z3, Canada. Email: [email protected]


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Haines-Saah et al. reporting that youth who smoked cigarettes were 9 to 15 times more likely to use cannabis than were nonsmokers. In British Columbia, the results from the 2008 McCreary Centre Society’s Adolescent Health Survey revealed that early initiation of alcohol or marijuana use and cigarette smoking were closely associated (Smith et al., 2009). Smith and colleagues found that 41% of teens who used these substances also identified as cigarette smokers. In contrast, among the population of adolescents who did not use marijuana or alcohol, only 10% identified as cigarette smokers. Others (Leatherdale, Hammond, Kaiserman, & Ahmed, 2006; U.S. Department of Health and Human Services, 2009) have also reported similar findings. Notions of identity are an important dimension of substance use. Identifying as a cigarette smoker involves more than simply engaging in the act of smoking tobacco (Johnson et al., 2003). Drawing on survey findings from a British Columbia study of youth (N = 8225), Okoli, Richardson, Ratner, and Johnson (2008) suggested that self-reported smoking identities and tobacco use patterns were strongly associated. Smoking (tobacco or marijuana) is a social and cultural phenomenon that shapes how one sees oneself. How adolescents strove to construct identities that contested social norms, mediated a confident self-image, and facilitated interpersonal relationships (Haines, Poland, & Johnson, 2009), and were closely linked to the consumption of tobacco. Smoking was strongly connected to peer networks and how adolescents defined themselves in relation to these group networks (Mitchell & Amos, 1997). Within contemporary culture, adolescents were exposed to a range of smoking images and identities with which to align that held more appeal than the messages in antitobacco campaigns, despite the well-known risks (Amos, Gray, Currie, & Elton, 1997). Even though an understanding of how smoking identities shape young people’s tobacco use has emerged, we know very little about how they navigate their identities in relation to multiple substances. In particular, there is a lack of in-depth qualitative exploration focused on the interplay between tobacco and marijuana use practices and social identity. Additionally, there is no research examining how youth evaluate the health risks and frame their decisions about the co-use of tobacco and marijuana. In this article, we address this gap in the Canadian context, describing how adolescents constructed types of smoking identities based on their views of the health and social implications of using marijuana and tobacco separately or together. Agrawal, Budney, and Lynskey (2012) have suggested that marijuana and tobacco co-use are linked in adolescence because both substances are smoked. There is a lack of agreement regarding the sequencing of initiation

of tobacco and marijuana use. Although several researchers have reported that young people initiated tobacco use prior to marijuana use (Ellickson et al., 2004; Henry, Oldfield, & Kon, 2003), an alternative reverse relationship has also been proposed (Patton, Coffey, Carlin, Sawyer, & Lynskey, 2005). Degenhardt et al. (2009) examined the progression of co-use through retrospective surveys of marijuana use initiation among adults 18 years and older. Based on survey findings, drug-use progression typically followed a normative pattern (i.e., tobacco use prior to marijuana use); however, among adolescents experiencing mental health problems exceptions were observed (Degenhardt et al., 2009). Although researchers have examined the potential relationship between marijuana and tobacco use, as well as the timing and order of initiation of these two substances, they have not addressed the specifics of co-use by adolescents (i.e., how, when, and why the two substances are combined). Within the research literature there are a number of explanations for co-use. For example, researchers have proposed that adolescents smoke tobacco to reduce the sedative effects of marijuana or to increase or prolong its rewarding effects (Tullis, Dupont, Frost-Pineda, & Gold, 2003; Viveros, Marco, & File, 2006). Others have suggested that mixing marijuana with tobacco (typically in a rolled “joint” or smoked in a pipe) causes marijuana to burn smoothly so that the effects are less harsh for the smoker (Patton et al., 2005). In one qualitative study, the research team explored adolescents’ perspectives on co-consumption and showed that youth preferred to smoke tobacco mixed with marijuana rolled in a cannabis cigarette because pure joints were too strong, too expensive, and did not burn evenly (Akre, Michaud, Berchtold, & Suris, 2010). In other studies, young people have reported believing that the health effects of marijuana were benign and that marijuana use could potentially reverse the damage caused by smoking cigarettes (Highet, 2004). Agrawal and colleagues (2012) suggested that multiple mechanisms influence this practice of co-use of marijuana and tobacco, namely shared biological mechanisms of action and genetic predisposition, common environmental influences, shared routes of administration, and preference for simultaneous use. Perceptions of risk also played an important role in shaping substance use and health-related discourses, practices, and identities (Lupton, 1995). The empirical evidence that focuses on the health implications of co-use of marijuana and tobacco is rather limited. Of particular concern are findings that higher rates of marijuana dependence and couse are linked (Agrawal et al., 2009; Ream et al., 2008), a result that has also been documented using animal studies (Marco et al., 2006; Valjent, Mitchell, Besson, Caboche, & Maldonado, 2002).


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In a British study, researchers found an association between the co-use of marijuana and tobacco and perceived nicotine dependence; youth participants described the close intertwining of marijuana use with cigarette use because marijuana was rarely smoked without being mixed with tobacco among this youth population (Amos, Wiltshire, Bostock, Haw, & McNeill, 2004). These young people explained how marijuana reinforced their addiction to cigarettes and heightened anticipated difficulties in quitting tobacco use. Indeed, although the risks of tobacco use are generally well known by the lay public, the health effects of marijuana use are less well studied and understood. There is emerging evidence that marijuana users are at increased risk of developing impaired mental health with earlier and more frequent use (Fergusson, Horwood, & Swain-Campbell, 2002; Lynskey et al., 2004). A recent systematic review highlights that a consistent consequence of marijuana and tobacco co-use among adolescents is worsening mental health symptomology (Ramo et al., 2012). Some researchers have suggested that marijuana, like tobacco, is a potential carcinogen (Hashibe et al., 2005), and that smoking marijuana could also lead to chronic bronchitis, impaired respiratory function, and increased rates of infection (Tashkin, Baldwin, Sarafian, Dubinett, & Roth, 2002). Other evidence related to the health effects of marijuana smoking is confusing, because although long-term marijuana smoking produced respiratory symptoms that appeared similar to those associated with tobacco smoke—such as increased coughing and sputum—smoking marijuana was not believed to contribute to chronic pulmonary obstructive disease (Owen, Sutter, & Albertson, 2013). In their systematic review, Tetrault et al. (2007) concluded that long-term marijuana smoking was associated with respiratory symptoms and complications, but inconclusive regarding pulmonary obstruction. In one recent longitudinal study, Pletcher et al. (2012) suggested that marijuana use was not associated with adverse pulmonary outcomes among individuals who used the substance occasionally. Confounding the debate were the inconclusive results regarding the possible carcinogenic effects of marijuana smoking on various cancers and the potential for marijuana to be used as a treatment and/or protective agent in various physical conditions (Owen et al., 2013). These mixed and potentially confusing findings result in young people (and adults) being unclear about the health effects of marijuana use. Ongoing developments in medical marijuana use add to the uncertainty about the risks of marijuana use and introduce a multifaceted element in terms of its cultural meaning. For instance, the cannabinoid derivative tetrahydrocannabinol (THC) was approved in Canada in 1982 to relieve the side effects of cancer chemotherapy. It has also been marketed in the

United States since 2006, and research has been conducted into the use of cannabis components as treatments for autoimmune disorders and malignancies (Owen et al., 2013). Within an extensive body of literature on identity accounts and drug use, Becker’s (1963) classic research on becoming a marijuana user underlines the notion that cultural meaning and expectations mediate the effects of drugs. Building on this tradition, we set out to understand how young people constructed particular types of smoking identities based on their views of the health and social implications of using marijuana and tobacco separately or together.

Methods We conducted a qualitative, descriptive analysis (Sandelowski, 2010) in which we drew on data from an ethnographic project that focused on the culture and context of frequent marijuana use among adolescents in three communities in British Columbia (one large urban center and two smaller cities). We selected these communities to represent geographic and social diversity and because of their liberal attitudes with regard to marijuana, which is common within the province (Mulgrew, 2005). We used observational (i.e., fieldwork, site visits) and interview methods to explore the social context of frequent marijuana use among adolescents in these communities, following details outlined by Johnson et al. (2008). From 2005 to 2009, we conducted individual interviews with 77 participants (31 girls and 46 boys) aged 13 to 18 years. The eligibility criteria for the study included recent marijuana use, defined as use occurring at least once within the previous week. Given our interest in incorporating a range of adolescents’ experiences with marijuana use, we chose to include several participants who indicated that they had recently tried to stop using marijuana. There were no explicit criteria for tobacco use employed in recruiting for this study. When asked about their tobacco use in the context of a pre-interview questionnaire, 34 participants (44%) indicated that they had smoked cigarettes on a daily basis and 38 identified as current smokers (49%). As researchers exploring co-use practices have demonstrated, these response categories do not adequately capture the tobacco use of those participants who engage in practices such as mixing tobacco and marijuana together, yet who do not identify themselves as cigarette smokers. Members of the University of British Columbia’s Behavioral Research Ethics Board granted ethical approval for the project. Recognizing the sensitivity of the topic of adolescent marijuana use, we successfully argued that adolescent participants could provide consent to participate in the study and did not require parental


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Haines-Saah et al. consent, given that young people were able to provide consent for medical procedures in hospital. We posted flyers with information about the study, along with contact information, within schools; in addition, study participants sometimes referred their friends to the research team. Prior to their interviews, we screened adolescents to determine eligibility based on current marijuana use patterns and their ability to speak English; we also obtained written consent at this time. We ensured confidentiality at the outset of the study and informed participants that all identifying information would be removed from the data. We invited participants to provide their parent(s) and/or guardian(s) with an information letter that outlined the purpose of the study as focusing on young people’s perspectives on marijuana. All interviews took place in a private setting, most often within the school environment. The interviewer and participant were not visible to members of the school community. In the urban center, however, a few students preferred to meet with the interviewer outside the school, in a coffee shop or university office setting. Participants received an honorarium to recognize their contributions to the research project. We used an interview guide that covered broad discussion categories during the interviews. These included history and patterns of marijuana use, contextual factors, reasons for use, knowledge and sources of information, as well as the co-use of other substances, including tobacco. During the course of the interview, we probed the participants’ understanding of the health risks associated with marijuana and tobacco. Given the age range of participants in this study, there was also diversity in terms of how they articulated their understanding of these risks. When the participants made comments related to their experience with tobacco within the context of regular marijuana use or when they referred to the differences between tobacco and marijuana, we encouraged them to elaborate. We recorded all interviews; they were then transcribed and checked for accuracy by members of the research team. The issue of tobacco and marijuana use was one of 20 broad codes applied to the findings during our preliminary analysis. We generated the initial 20 codes from the topics in the interview guide and from the saturation of themes that occurred across the 77 interviews. These codes were exhaustive, but not mutually exclusive. We used NVivo qualitative data analysis software (QSR International, 2012) in the coding as a strategy for the organization and retrieval of the findings. For the analysis reported here, we focused on the code that specifically addressed marijuana and tobacco co-use. We then conducted a more refined analysis and subcoding within this code, paying attention to the perspectives the teens took in relation to tobacco and marijuana. This coding

approach allowed us to identify notions of identity, risk, and the transitions youth made in their substance use.

Findings We inductively identified three categories to describe the different identities and practices of the young people. These categories we named the “purists” (i.e., those who smoked marijuana only and took a strong antitobacco stance), the “mixers” (i.e., those who smoked marijuana combined with tobacco but did not consider themselves tobacco smokers), and the “tobacco smokers” (i.e., those marijuana smokers who also identified as tobacco smokers). Of the 77 young people we interviewed, 68 aligned clearly with one of these identities, but the others were less easy to classify. The largest proportion of participants identified as tobacco smokers (regular or occasional), followed by marijuana purists, and finally by marijuana and tobacco mixers.

The Purists The purists were the young people who smoked marijuana but maintained a firm stance against smoking tobacco. Included among the purists were the self-identified former cigarette smokers who smoked only marijuana at the time of the interview. Nearly one third of the participants fit within this category. These young people were adamantly against tobacco, to such an extent that they refused to smoke marijuana if it was rolled with or mixed with tobacco. One participant shared, “There’s a lot more bad stuff that goes into tobacco I guess. There’s like THC in marijuana . . . but there’s just too much disgusting stuff that’s in tobacco that I’d never want to even go near.” The purists expressed impassioned antismoking views and readily described cigarettes as gross, dirty, unattractive, and addictive, whereas they considered marijuana to be natural. Rarely did purists refer to marijuana as a substance that was potentially harmful or addictive. A number of these participants emphasized how smoking tobacco was a “pointless” activity and were quick to dismiss any positive effects or benefits from tobacco use. One participant concluded, I’m very against cigarettes. There’s no pros to that I don’t think personally. There are pros and cons to everything, but the cons outweigh the pros that much, right? You’re just killing yourself. . . .With smoking, it doesn’t really do anything, you’re just stuck to it, there’s no purpose.

Another purist held a firm position against the image associated with tobacco, elaborating on all the negative aspects:


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Never. I’ve never even like, I’ve never held a lit one.… Cigarettes don’t do anything; they’re just like an image that you don’t need. You look gross when you smoke them. It’s just like, it smells bad, it’s a waste of money, and it doesn’t get you high. There’s no point like at all. I wouldn’t smoke pot [marijuana] if it didn’t get you high.

While distancing himself from the futility of smoking tobacco, this purist framed his decision to smoke marijuana in a matter-of-fact fashion. There was a purpose to marijuana use: to get high. Many purists focused on the negative health consequences associated with tobacco use. Likely influenced by antitobacco campaigns, these youth claimed to be opposed to smoking tobacco primarily for health reasons and positioned themselves accordingly. Whereas purists professed to know a lot about the “bad stuff” in tobacco, some admitted that they knew little about the harms associated with marijuana use. For example, one youth admitted, “I guess there’s like THC in marijuana. But I guess I don’t know all the stuff that’s in marijuana.” Typically, purists referred to tobacco use as a cause of cancer that could lead to death; however, a number of these participants suggested they were unaware of any carcinogenic properties linked to marijuana use. One participant revealed, “I’ve never heard of anybody getting cancer from it, like weed, that’s the reason why I’ve done it.” In contrast to tobacco, participants viewed marijuana as a comparatively better choice. The purists argued that marijuana was a “cleaner” and “healthier” option. These youth frequently referred to the many “disgusting” chemicals in tobacco and seemed to ignore the fact that, like marijuana, tobacco is also a plant. According to one participant, It [marijuana] is an actual herb, so it came from the earth. It grows here, it’s a natural, something natural, um, natural source I guess, and tobacco is something made with a whole bunch of products, and it’s disgusting stuff.

Purists also maintained that marijuana was safer than tobacco, supporting their decision to use marijuana only. In this way, participants framed any potential negative effects from smoking marijuana as less harmful, given that the practice of marijuana use involved smoking it less frequently than cigarettes. One participant explained: “Cigarettes are worse, too, because you don’t smoke weed as much as you smoke cigarettes.…My brother, he smokes cigarettes and he doesn’t smoke weed anymore. He smokes like between five and ten cigarettes a day.” This participant was one of the few purists who acknowledged possible harms with marijuana use: “Marijuana is a lot safer than tobacco because tobacco kills you and marijuana doesn’t, so well, unless you’re driving or doing something really dumb when you’re on marijuana.” In

this way, this young boy suggested that the health risks associated with marijuana use could be minimized and deflected by behavioral decisions, namely avoiding use at certain times. Purists’ concerns about tobacco use extended to family members and friends; some young people described how they encouraged others to stop smoking cigarettes. When necessary, some instructed family members to smoke cigarettes outdoors to minimize other’s exposure to smoke: I told [my mom] to do it outside because I was finding it hard to like…I’d go for a run and just, it’s a lot harder to breathe because it’s worse. Ever since I told her to go outside it’s, I’m fine now.

For this participant, personal cannabis use was exempt from contributing to breathing difficulties. Other purists eschewed the co-use of tobacco and marijuana because they did not enjoy the physical sensations that resulted from smoking these substances together. One young woman was pragmatic and refrained from co-use because she would be “less high” if she mixed tobacco with marijuana. Individuals who had previously had a negative experience from mixing marijuana and tobacco became purists. One boy recalled an isolated experiment while mixing— “I got light-headed and it didn’t feel good”—and another purist described “a really massive head rush and feeling really dizzy ’cos of the nicotine.” Some participants focused on their aversion to the taste of mixing, equating it to “eating dirt.” One teen emphasized the inherent risks associated with mixing while distancing himself from mixers, whom he referred to as “the head-rush people”: I tried [mixing], but I think it’s just, it tastes awful like, yeah marijuana has a bad taste but I think it’s, no, I just wouldn’t do it.…Yeah, that’s why, the head-rush people say it gives them a better head rush. I’m like, well it only gives you a head rush for thirty seconds and you’d want another one right away, you’d get addicted to cigarettes and, yeah.

Of note, one participant positioned himself as a purist even though he admitted to using organically grown tobacco with marijuana as a strategy to circumvent the chemicals found in commercial tobacco. By deciding to use a pure source of tobacco, he claimed to be taking charge and therefore minimizing the harms associated with tobacco: I roll my own with like, organic tobacco.…It’s screwed up, how much chemicals are in it [commercial tobacco]. Like, they put so much chemicals in it. That’s like half of what gives you a huge head rush, all the chemicals you’re taking in at once.


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Haines-Saah et al. Although not opposed to tobacco on moral or health grounds, another purist was deliberate in his decision to abstain from tobacco because he perceived it was a probable threat to continued marijuana use: One of the biggest reasons [for not smoking tobacco] is I want to save my lungs for weed [marijuana]. I love smoking weed. It’s like a really fun pastime. But cigarettes, it would just make my lungs worse and enable me, make me smoke less weed if I have the same degree of lung capacity.

This participant was adamant that there were no risks involved in smoking marijuana. Although some purists avoided the co-use of marijuana and tobacco based on previous negative experiences, participants in the mixer category described engaging in co-use because they enjoyed a greater high or a “rush” when smoking both substances together.

The Mixers The self-professed mixers, the smallest category represented in the sample, described a range of practices they used to combine tobacco and marijuana. Most often this involved mixing tobacco and marijuana by rolling the two substances together with a cigarette wrapper (joint) or in a bong (a water-filtered pipe used for smoking marijuana). Participants often referred to these methods of combining the two substances as a “rocker,” so-called because the combined use created a strong sensation that “rocks” the user with a head rush or “body buzz.” Some participants also mentioned smoking cigarettes dipped in marijuana-derived oil, using a hookah (a water-filtered pipe of Middle Eastern origin), a chillum (a cone-shaped pipe of Indian origin), or in a blunt (marijuana rolled in the hollowed out tobacco leaf wrapper from a cigar). Marijuana was also mixed with tobacco and inserted into a partially emptied filtered cigarette when no paper wrappers were available to roll a joint. By using tobacco to create a rocker effect, mixing marijuana with tobacco also served to extend the amount of marijuana smoked in a joint, pipe, or bong when a limited amount of the drug was available. For some adolescents, the co-use of tobacco and marijuana occurred sporadically, although for others mixing both substances was a well-established routine. In relation to their tobacco use, mixers self-identified as nonsmokers or social smokers. Unlike the purists, they were not vehemently opposed to tobacco. This meant that those who were infrequent mixers did not associate being a tobacco smoker with their smoking of rockers or engaging in other forms of tobacco and marijuana co-use intermittently. As one youth described it, “No, to this day I still don’t smoke cigarettes. I have occasionally smoked some tobacco with pot or like hit, a cigar at a party, but I’m not a smoker at all.”

Other mixers, however, described themselves as social smokers who did not have a daily pattern of cigarette use. Of interest, when they were mixing or smoking tobacco socially, these youth expressed their confidence in maintaining irregular co-use practices and not becoming addicted to tobacco. That said, some participants conveyed cautious awareness that co-use of both substances could possibly lead to nicotine addiction. For one mixer, a proposed protective strategy to avoid unwelcome nicotine addiction was to ensure that the practice of mixing remained sporadic: I’ve had cigarettes. I have a really strong belief in myself so I can’t get addicted to cigarettes. Like I could smoke one right now and then not have any cravings or anything towards it. I have really good self-control. I do mix though once in a while.…I don’t want [to combine marijuana and tobacco] all the time because I don’t want to get addicted.

Another mixer, who maintained that he had never smoked a cigarette, expressed a motivation to stop smoking marijuana that was related to his perception that he was addicted to the tobacco that he regularly combined with it: [I use]…bong tokes [inhalations] because, I don’t know, that’s pretty much how we smoke them here, through bongs with tobacco.…It’s just not as harsh like on the throat; it’s more like, smooth, and easier to enjoy I guess.…It’s a habit I guess you start with. I’ve never smoked a cigarette and I doubt I ever will. The biggest reason I want to quit smoking [marijuana] is because I realize that I’m more addicted to the tobacco that we mix with it.

This participant situated his marijuana use in a social context in which bongs were widely used, and where it was common that tobacco and marijuana were mixed together. For this young man, there was a clear distinction between those who mixed tobacco with marijuana and those who smoked cigarettes on their own. Although he did not see himself as a tobacco smoker, he none theless expressed his intention to stop using marijuana because of his addiction to tobacco resulting from the mode of co-use, namely combining tobacco and marijuana in a bong. During the course of the interview the mixers, unlike the purists, did not emphasize their concerns about the health effects of smoking tobacco (i.e., cancer, respiratory issues) other than worrying about the potential for addiction. Although they participated in a regular practice of mixing the two substances and enjoying the experience of co-use, many mixers were also careful to distance themselves from the identity of the regular and addicted tobacco smoker. These mixers remained in a type of middle zone.


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The Tobacco Smoker The participants who were regular tobacco smokers (nearly one half of the sample) expressed preferences both for and against its co-use with marijuana. Some were opposed to co-use, whereas this was a common practice for others; most were vocal about their preferences and established habits. For example, one young person had been smoking tobacco for 4 years and questioned why others engaged in co-use: “Well, I don’t get why you would [co-use]. Just go to have a smoke after!” Another long-term tobacco smoker, very much aligned with the views of the purists, described that her approach was aimed at keeping tobacco use separate from marijuana use as a way to ensure that her marijuana was “clean”: It’s because in pot, you’ve still got your, a little bit of nicotine, right? But in cigarettes you’re just adding more nicotine to it and more tar, and then you’re adding battery acid and the rat acid and you’re adding more stuff to your pot. I’d rather have my pot as clean and pure as possible than adding things to it.

This participant intimated that marijuana use could be harmful, but falsely believed that marijuana contained nicotine, as do cigarettes. She therefore operated from a desire to avoid combining the two substances in an effort to evade the harmful substances present in tobacco. Like the purists, some tobacco smokers abstained from co-use because they did not enjoy the intense physical sensations that resulted from mixing marijuana and tobacco. One tobacco smoker described an isolated occasion when he used only tobacco in his bong: I’ve done [co-use] once but I didn’t like it. It’s a weird feeling smoking tobacco without a filter. When I first did it, it was a long time ago when me and my friends started smoking. The tobacco is shot right into the lungs.…I didn’t like it.

Another tobacco smoker was more ambivalent about his intermittent practice of using a bong and taking a “rocker toke,” suggesting a co-use practice that was fluid: I started doing rockers and whatnot and it did almost make you get more high because you’re sitting there like, just rocking for a minute. It goes away after a couple of seconds, it’s almost just pointless. Like yeah, I’ll take a rocker toke sometimes but other times I won’t, so.

As noted, some tobacco smokers opposed any form of mixing. Rather, they frequently described having a cigarette separately soon after smoking marijuana, commonly referred to as the “after-toke smoke.” This specific form of co-use was routine practice, a way to enhance the high or effects of marijuana. As one participant described it, “I

always have a cigarette after I smoke a joint, always. Habit. You just want one more; it’s like after eating.” The explanation that tobacco smokers provided for this pattern of co-use was that it made the experience of smoking marijuana more enjoyable. One young woman contended, “[Co-use is] supposed to increase your high by thirty percent or something like that.” Another participant, however, recognized the downside of “bring[ing] up the high”: I just find I have a cigarette after I smoke marijuana because I don’t know, it’s just like, I feel like I need a cigarette and it’s like, it feels like good, kind of. I don’t know, it’s just like kind of relaxing.…It does bring up the high, but you burn out quicker, almost.

In this way, some youth were learning how to control the ups and downs related to using both substances. Other tobacco smokers had calculated methods of couse, with established practices linked to practical considerations. In addition to using tobacco to enhance their high, their co-use functioned as a way to extend or “save” the amount of marijuana or tobacco, a concern for some participants who periodically had limited access to either substance. Parallel to what the mixers revealed, tobacco smokers were also concerned about extending or supplementing their supply of marijuana. The social context meant they varied how they went about this: [Mixing] kind of saves you with pot because you’re—I can’t do that when I’m with my boyfriend, though, because he doesn’t smoke cigarettes, so he thinks that’s absolutely disgusting. But I’ll do it, if I’m out camping. Hell, yes, it’s so much fun. It saves me tobacco and it saves me pot. I’m winning both ways.

A number of participants alluded to the cost of both substances. One teen echoed this sentiment and described the practice of spontaneous bartering that occurred among peers who also engaged in tobacco and marijuana co-use: Yeah, like say I had not very much weed, and you had not very much tobacco. I could be like, okay, we could both take a bong toke if you give me a little bit of your rocker and I’ll give you a little bit of my weed and then we’d both put in, so.

In terms of the day-to-day practices of co-use, some tobacco smokers framed cigarettes as providing suitable camouflage for marijuana use. For instance, one participant recounted the convenience of storing a partially used joint in his cigarette pack to smoke at a later time. One girl noted how tobacco and marijuana co-use “helps to hide the smell. And if there’s like, steam, you can be just like, ‘I have a cigarette,’” adding, “No one’s going to yell


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Haines-Saah et al. at me for smoking [cigarettes].” A few participants suggested that they substituted tobacco for marijuana at times of need, as occurred when co-use was impossible at school or during a long car trip with family members, highlighting the practical short-term interchangeability between the two substances.

Shifting Identities Although most participants fell neatly within the categories of purist, mixer, or tobacco smoker, there were a few youth who appeared to transition across these identities. For example, some participants described themselves as former or ex-tobacco smokers who no longer smoked tobacco but continued to smoke marijuana. Additionally, among those who identified as former tobacco smokers, not all were purists or mixers. For example, one participant stated that he was still a casual or social cigarette smoker as well as a frequent marijuana smoker. New understandings of risk and changing social contexts often influenced these shifting identities. Several participants revealed that they had stopped or that they intended to stop using tobacco for health reasons. Few young people we interviewed raised the issue of needing to quit or cut back on their use of marijuana because of concerns about specific health effects. The effects they mentioned in relation to smoking marijuana included its impact on physical endurance and lung capacity, and beliefs that it “kills brain cells,” “burns you out,” and contributes to a lack of focus and concentration. Although most participants in this study engaged in frequent and often daily marijuana use, and did not focus on quitting per se, some expressed a desire to reduce marijuana consumption. This occurred when participants noticed their use had increased over time, that they were becoming dependent on marijuana, required increased amounts to get high, or that they could no longer afford to buy marijuana. Even though these participants saw frequent use of marijuana as less harmful than smoking tobacco, there was some recognition that their use had progressed and become problematic over time: Pot is like a cigarette except healthier.…For cigarettes, you could be just smoking four cigarettes and soon you’re up to a pack. To me, that’s the same thing with the pot. I smoke a lot more than I used to when I first started.

Despite this participant viewing marijuana as “healthier,” she also noted that her tobacco and marijuana use had both increased, although she did not frame this as an issue of dependency at the time of the interview. Some participants did consider their use of marijuana as an addiction and spoke about wanting to quit or reduce their use, but not being ready to, or not knowing how to do this successfully.

Discussion Descriptive analysis of our data revealed that adolescent polysubstance use was more than simply pharmacologically driven; rather it was linked to social identities, couse practices, and beliefs about the health effects of these particular substances. Adolescent tobacco use has been documented extensively in regard to identity (Baillie, Lovato, Johnson, & Kalaw, 2005; Denscombe, 2001; Michell & Amos, 1997; Plumridge, Fitzgerald, & Abel, 2002; Rugkåsa et al., 2001; Rugkåsa, Stewart-Knox, Sittlington, Santos Abaunza, & Treacy, 2003), and our findings illustrate how adolescent marijuana use and social identities are also linked. Participants in our study expressed a particular identity as purist, mixer, or tobacco smoker through explaining their co-use practices. In interviews, adolescents disclosed their smoking practices by speaking about the pros and cons of mixing marijuana with tobacco, rolling it with paper or cigar wrappers, and other modes of use; these two forms of smoking reinforced each other. For these young people, it was notable that they did not associate the risks of marijuana use with its status as an illegal drug or so-called “outlaw” identity. Arguably, the participants viewed tobacco use as much more stigmatized, harmful to health, and as carrying greater potential for addiction. Indeed, many suggested that tobacco was more difficult to obtain than was marijuana. These findings contribute to the literature on identity and risk by illustrating how, in a social climate of equivocal knowledge about the harms of marijuana and strong stigma against tobacco, adolescents selected information about the risks that best matched, and they rationalized their pattern of use. The findings are potentially limited in that the participants all lived in British Columbia, known as the province with the lowest tobacco smoking rate in Canada, and as a place where a number of marijuana advocates have raised awareness regarding the putative benefits of marijuana use (Mulgrew, 2005). These contextual factors inevitably shaped the participants’ views about tobacco and marijuana. Given the findings of past research on adolescent tobacco use, it is perhaps not surprising that the mixers in our study did not view themselves as tobacco smokers, although some regularly consumed tobacco with marijuana. Following earlier studies, researchers concluded that just because young persons smoked, it did not necessarily mean they identified themselves as a smoker or as addicted to tobacco. Rather, identification as a smoker shifted alongside different frequencies and amounts of smoking (Bottorff et al., 2004; MacFayden, Amos, Hastings, & Parkes, 2003; Moffat & Johnson, 2001), and adolescents were known to espouse a range of smoker and nonsmoker identities (Johnson et al., 2003).


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Another potential limitation is that the findings we collected from 2005 to 2009 are now between 5 and 9 years old. Although the practice of tobacco/marijuana couse might have shifted since the time of our data collection, we are confident that the social context of co-use has not undergone significant changes and that our findings are still relevant. Understanding smoker identities from the perspectives of adolescents has significant implications for cessation supports, chiefly because in a similar study focused on tobacco use only, some adolescents did not perceive themselves as addicted, nor see themselves as invincible from tobacco dependence (Moffat & Johnson, 2001). The findings of our study echo this point, particularly among those in the mixer category. Tobacco prevention and cessation programming have generally missed these subtleties by using a blanket approach that runs the risk of alienating subgroups of smokers (Amos, Wiltshire, Haw, & McNeill, 2006; Haines et al., 2009). Accounting for these variations in adolescents’ views on smoking identities and status would strengthen marijuana prevention efforts by incorporating tailored approaches for co-users that articulate the separate risks of tobacco and marijuana. This is important in light of research indicating increased risk of cannabis dependence among those who co-used marijuana and tobacco (Ream et al., 2008). Harm-reduction approaches that aim to reduce exposure to both marijuana and tobacco smoke seem particularly appropriate for this group. Indeed, some of the study participants’ language around what was better and worse for their health underlined the strategies some young people used to control their use of tobacco and to reduce health harms from smoking (Johnson, Kalaw, Lovato, Baillie, & Chambers, 2004). Finally, as our findings suggest and as recently described by Akre et al. (2010), although adolescents were well-versed in the health harms associated with tobacco use, they generally saw marijuana use as “natural” and not harmful to their health. Participants exemplified this misinformation and stated with confidence that marijuana was not carcinogenic, that it contained nicotine, and that it was a natural plant that contained no chemical additives. This is far from the case for illegal marijuana crops grown using unregulated chemical pesticides. Unlike the findings of Akre and colleagues, in which marijuana joints were always mixed with tobacco, the responses from purists in our study revealed that many young people identified as purists and did not engage in coconsumption. To reduce marijuana smoking among adolescents in this subgroup, health messaging needs to first be aimed at identifying how best to clarify and communicate the different risks associated with recreational marijuana smoking vs. medical use within a social climate that tends to minimize all harms. Further

work is needed in this area, including harm-reduction messages that are well received by adolescents. In countries such as Canada, considerable investments have been made toward antitobacco campaigns within schools, but there is less-consistent and often conflicting health messaging regarding the topic of marijuana. Our findings uncovered the confusion that abounds regarding the risks associated with smoking marijuana, in sharp contrast to the knowledge that young people have about the immediate and long-term effects of tobacco use. Given this apparent disjuncture in adolescents’ views of the health effects of marijuana, current prevention and education initiatives would do well to develop comprehensive messaging that addresses the adverse respiratory complications of marijuana when smoked and the potential for dependence, either on its own or when combined with tobacco. In British Columbia, the programing directed at the prevention of tobacco and marijuana use has traditionally been funded by separate sources and has not overlapped. Increased efforts to address the health risks involved in the practice of smoking both tobacco and marijuana are certainly indicated and overdue. Most of the participants we interviewed had definite patterns, preferences, and reasons for and against co-use; as such, messaging also needs to account for different practices and changing contexts, and messages tailored accordingly to address youth marijuana use among purists, mixers, and tobacco smokers alike. Acknowledgments We thank the young people who shared their experiences so openly.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support was received from the Canadian Institutes of Health Research.

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Author Biographies Rebecca J. Haines-Saah, PhD, is a sociologist and research associate at the University of British Columbia School of Nursing in Vancouver, British Columbia, Canada. Barbara Moffat, MSN, is a project director at the University of British Columbia School of Nursing in Vancouver, British Columbia, Canada. Emily K. Jenkins, MPH, is a doctoral student at the University of British Columbia School of Nursing in Vancouver, British Columbia, Canada. Joy L. Johnson, PhD, FCAHS, is a professor at the University of British Columbia School of Nursing in Vancouver, British Columbia, Canada, and the scientific director of the Canadian Institutes of Health Research Institute of Gender and Health.


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