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Achieving Health Equity: Toward a Commercial Tobacco-Free California, 2021-2022

Objective 3: Broaden the public health framework for tobacco to address the triangulum of tobacco, cannabis, and e-cigarettes

 E-cigarettes and other vaping devices have created a large area of overlap between tobacco and cannabis. E-cigarettes were initially introduced and marketed as an alternative to cigarettes for smokers unwilling or unable to quit. However, they have led to an unprecedented epidemic among American youth, driven by widespread targeted marketing, social media, and thousands of flavored products.35 As e-cigarette use has grown in popularity, so has cannabis use, including cannabis vaping.22 During the e-cigarette or vaping product use-associated lung injury (EVALI) health crisis of 2019-2020, thousands of people, many of them young, were hospitalized and/or died.36 California youth now use e-cigarettes more than cigarettes (10.9 percent vs. 2.0 percent in 2017-18), with cannabis use higher than overall tobacco use (14.7 percent vs. 12.7 percent).10  At the same time, there is a strong positive correlation between tobacco use and cannabis use.22 Co-use, dual use, poly use, and sequential use have become common,20,21 exacerbated by the widespread availability of vaping devices for both tobacco and cannabis, including some that can be used with multiple substances.


Just as the overlap between tobacco and cannabis products is increasing, so is the overlap between the industries that produce them. The cannabis industry in California was once a loose network of independent businesses. It has since become corporatized and, like the tobacco industry, has lobbying power in Sacramento.37 It employs similar predatory marketing tactics to drive use in vulnerable communities.38 Tobacco companies have bought stakes in cannabis companies, and new products are emerging that contain both tobacco and cannabis.39 


These intersections represent a challenging minefield that threatens to undo much of the tobacco control movement's progress.40,41 The medical use of cannabis falls outside the scope of tobacco control and is therefore not addressed in this plan. The Triangulum of Tobacco, Electronic Smoking Devices, and MarijuanaThe Triangulum of Tobacco, Electronic Smoking Devices, and Marijuana. (Image credit: Lucy Popoval)

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​​ ​References

10. Zhu S, Zhuang YL, Braden K, et al. Results of the statewide 2017-18 California Student Tobacco Survey. San Diego, CA: Center for Research and Intervention in Tobacco Control (CRITC), University of California, San Diego;2019.

20.  Nguyen N, Barrington-Trimis JL, Urman R, et al. Past 30-day co-use of tobacco and marijuana products among adolescents and young adults in California. Addict Behav. 2019;98:106053. doi:10.1016/j.addbeh.2019.106053.

21. Tucker JS, Pedersen ER, Seelam R, Dunbar MS, Shih RA, D'Amico EJ. Types of cannabis and tobacco/nicotine co-use and associated outcomes in young adulthood. Psychol Addict Behav. 2019;33(4):401-411. doi:10.1037/adb0000464.

22. Meng Y, Ponce NA. The Changing Landscape: Tobacco and Marijuana Use Among Young Adults in California. UCLA Center for Health Policy Research; June 2020.

35. Volkow N. Monitoring the Future survey raises worries about teen marijuana vaping.  December 18, 2019.

36. Belok SH, Parikh R, Bernardo J, Kathuria H. E-cigarette, or vaping, product use-associated lung injury: A review. Pneumonia (Nathan). 2020;12:12. doi:10.1186/s41479-020-00075-2.

37. Barry RA, Glantz SA. Marijuana regulatory frameworks in four US states: An analysis against a public health standard. Am J Public Health. 2018;108(7):914-923. doi:10.2105/ajph.2018.304401.

38. Ayers JW, Caputi TL, Leas EC. The need for federal regulation of marijuana marketing. JAMA. 2019;321(22):2163-2164. doi:10.1001/jama.2019.4432.

39. Roberts C. Tobacco giant Altria is securing technology in new frontier: Marijuana. Forbes. 2020. ( Accessed January 27, 2021.

40. McDonald EA, Popova L, Ling PM. Traversing the triangulum: The intersection of tobacco, legalised marijuana and electronic vaporisers in Denver, Colorado. Tob Control. 2016;25(Suppl 1):i96-i102. doi:10.1136/tobaccocontrol-2016-053091.

41. Tobacco Education and Research Oversight Committee. The Triangulum: Tobacco, Marijuana, and Electronic Smoking Devices (ESD).  September 29, 2016.

42. California Business and Professions Code, § 22950.5(d)(1).

43. California Health and Safety Code, §11362.3.

44. Schmidt LA, Jacobs LM, Spetz J. Young people's more permissive views about marijuana: Local impact of state laws or national trend? Am J Public Health. 2016;106(8):1498-1503. doi:10.2105/ajph.2016.303153.

45. Silver LD, Naprawa AZ, Padon AA. Assessment of incorporation of lessons from tobacco control in city and county laws regulating legal marijuana in California. JAMA Netw Open. 2020;3(6):e208393. doi:10.1001/jamanetworkopen.2020.8393.

46. Amiri S, Monsivais P, McDonell MG, Amram O. Availability of licensed cannabis businesses in relation to area deprivation in Washington state: A spatiotemporal analysis of cannabis business presence between 2014 and 2017. Drug Alcohol Rev. 2019;38(7):790-797. doi:10.1111/dar.12987.

47. Fiala SC, Dilley JA, Firth CL, Maher JE. Exposure to marijuana marketing after legalization of retail sales: Oregonians' experiences, 2015-2016. Am J Public Health. 2018;108(1):120-127. doi:10.2105/ajph.2017.304136.

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