Association of Cannabis Use With Cigarette Use in People Certified for Medical Cannabis for Chronic Pain: A Secondary Analysis of a Prospective Cohort Study.

Slawek D.; Zhang C.; Nangia G.; Nahvi S.; Minami H.; Levin F.; Sohler N.; Calderon DiFrancesca G.; Cunningham C.; Arnsten J. et al. · Substance use & addiction journal · 2026

**Background & Methods** This secondary analysis examined a prospective, longitudinal cohort study of 223 adults with chronic pain who were opioid users and newly certified for medical cannabis in New York State. Participants completed quarterly questionnaires over 9 months assessing cannabis use, cigarette use, pain severity, anxiety, and depression, with four two-step mixed-effect models evaluating the longitudinal relationship between cannabis use patterns and cigarette consumption. **Key Findings** • Unregulated cannabis use (β = .058, P = .002) and mixed cannabis use sources were associated with increased cigarettes per day (CPD), while non-inhaled cannabis use was negatively associated with CPD (β = -.015, P = .015), suggesting route and source of cannabis differentially impact cigarette consumption. • Pain severity moderated the relationship between cannabis use and cigarette use; cannabis use was positively associated with CPD at pain severity scores below 6.73, but negatively associated above this threshold, indicating pain intensity influences whether cannabis substitutes for or complements cigarette use. • At baseline, 73.5% of participants (164/223) used cannabis and 33.6% (75/223) used cigarettes, with any cannabis use alone showing no significant association with cigarette use when pain severity was not considered. **Dosage & Administration** Not reported. The study measured frequency of use (days in past 30 days) and route of administration (inhaled versus non-inhaled) but did not specify cannabis doses or THC/CBD concentrations. **Safety & Adverse Effects** Not reported. The study did not assess or report adverse effects or safety outcomes related to cannabis or cigarette use. **Evidence Quality** This secondary analysis has notable limitations: it relies on self-reported substance use data subject to recall and social desirability bias; the sample is restricted to New York State residents certified for medical cannabis, limiting generalizability; the cross-sectional nature at baseline and modest sample size reduce causal inference capability; and potential confounding variables affecting the cannabis-cigarette relationship were not fully controlled. The findings represent moderate evidence (observational cohort data) requiring validation through larger, more rigorous prospective studies and controlled trials.

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