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Cannabis–nicotine co-use is increasingly driven by vaping devices and nicotine pouches rather than cigarettes.

Perceived risks of cannabis continue there decline even as perceived harms of tobacco continue to rise.

Nicotine and cannabis reinforce one another through shared brain reward pathways, increasing dependence risk.

Modern nicotine delivery systems and changing norms have made THC–nicotine co-use common but mostly invisible.

Cigarette smoking among American adolescents has fallen to historic lows, representing one of the most significant public health successes of recent decades. Yet nicotine exposure has not disappeared; it has simply changed form. Today, many youth encounter nicotine through alternative products such as e-cigarettes and nicotine pouches, which supply nicotine orally without requiring the constant spitting associated with traditional smokeless tobacco. While these products may reduce many harms associated with combustible cigarettes, they can still lead to chronic nicotine dependence.

Is Youth Nicotine Exposure Really Declining?

As a result, it is premature to declare victory; youth nicotine exposure may not be declining as rapidly as cigarette smoking rates alone suggest. Although nicotine remains the most common substance used in e-cigarettes, cannabis vaping has become progressively prevalent. Studies indicate that approximately 30% to more than 50% of adolescents who use e-cigarettes also report vaping cannabis or THC. Historically, cannabis–nicotine co-use primarily involved combustible products—cannabis and cigarettes. Increasingly, however, this combination occurs through noncombustible products, especially cannabis and nicotine vaping devices. Nicotine pouches represent a newer nicotine source that may further diversify patterns of co-use among youth.

This shift matters because cannabis/THC–nicotine co-use has emerged as an important psychiatric and public-health concern, particularly among adolescents and young adults. Although cannabis and tobacco have traditionally been studied separately, growing evidence suggests their combined use represents a potentially higher-risk pattern of substance exposure.

Health Risks Associated with Cannabis and Nicotine Co-Use

Co-use of cannabis and nicotine is associated with greater dependence liability, heavier substance use, cognitive impairment, cardiovascular and pulmonary injury, and growing evidence of adverse psychiatric outcomes. Both nicotine and THC may produce acute cardiovascular effects, including tachycardia, sympathetic activation, and blood-pressure changes, raising concerns that combined exposure may amplify cardiovascular risks.

Today's cannabis co-user is often combining nicotine with far more potent THC exposures than earlier generations experienced. THC concentrations in legal and illicit products are substantially higher, particularly in vape concentrates, where THC levels may exceed 70%-90%.

Prevalence of Concurrent Cannabis and Nicotine Use

More than 16 million Americans report concurrent cannabis and tobacco use. Among regular cannabis users, nicotine is the most common co-occurring substance. Depending on the population studied, approximately one-half to two-thirds of regular cannabis users use nicotine. The highest rates occur among adolescents and young adults, the same developmental period associated with peak vulnerability to addiction, psychosis onset, and long-term neuropsychiatric........

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