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Original Investigation
August 12, 2019

Association Between Electronic Cigarette Use and Marijuana Use Among Adolescents and Young Adults: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
  • 3Harvard Chan School of Public Health, Boston, Massachusetts
  • 4Danish Clinical Quality Program, National Clinical Registries, Aarhus, Denmark
JAMA Pediatr. 2019;173(10):e192574. doi:10.1001/jamapediatrics.2019.2574
Key Points

Question  Is electronic cigarette (e-cigarette) use associated with marijuana use in adolescents and young adults?

Findings  In this systematic review and meta-analysis, the odds of past or current marijuana use among youth who used e-cigarettes were 3.5 times higher than for those who denied e-cigarette use; this association was significant in both cross-sectional and longitudinal studies. Studies conducted in adolescents aged 12 to 17 years (vs young adults aged 18 to 24 years) showed a stronger association between e-cigarette and marijuana use.

Meaning  These findings suggest that clinical and regulatory approaches to managing e-cigarette use among youth amid the current trend of marijuana legalization should consider the significant association between e-cigarette and marijuana use.


Importance  Use of electronic cigarettes (often called e-cigarettes) has increased considerably among young people in the past 5 years. Use of e-cigarettes has been associated with higher rates of marijuana use, which is associated with several adverse health outcomes in youth.

Objective  To characterize and quantify the association between e-cigarette and marijuana use among youth using a meta-analysis.

Data Sources  PubMed, Embase, and Web of Science & ProQuest Dissertations and Theses were searched from inception to October 2018. A gray-literature search was also conducted on conference abstracts, government reports, and other sources.

Study Selection  Included studies compared rates of marijuana use among youth aged 10 to 24 years who had used e-cigarettes vs those who had not used e-cigarettes. Two reviewers independently assessed studies for inclusion; disagreements were discussed with a third reviewer and resolved by consensus.

Data Extraction and Synthesis  Data were extracted by 2 independent reviewers following Meta-analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines and pooled using a random-effects analysis. The Newcastle-Ottawa Scale was used to assess data quality and validity of individual studies.

Main Outcomes and Measures  Adjusted odds ratios (AORs) of self-reported past or current marijuana use by youth with vs without past or current e-cigarette use.

Results  Twenty-one of 835 initially identified studies (2.5%) met selection criteria. The meta-analysis included 3 longitudinal and 18 cross-sectional studies that included 128 227 participants. Odds of marijuana use were higher in youth who had an e-cigarette use history vs those who did not (AOR, 3.47 [95% CI, 2.63-4.59]; I2, 94%). Odds of marijuana use were significantly increased in youth who used e-cigarettes in both longitudinal studies (3 studies; AOR, 2.43 [95% CI, 1.51-3.90]; I2, 74%) and cross-sectional studies (18 studies; AOR, 3.70 [95% CI, 2.76-4.96]; I2, 94%). Odds of using marijuana in youth with e-cigarette use were higher in adolescents aged 12 to 17 years (AOR, 4.29 [95% CI, 3.14-5.87]; I2, 94%) than young adults aged 18 to 24 years (AOR, 2.30 [95% CI, 1.40-3.79]; I2, 91%).

Conclusions and Relevance  This meta-analysis found a significant increase in the odds of past or current and subsequent marijuana use in adolescents and young adults who used e-cigarettes. These findings highlight the importance of addressing the rapid increases in e-cigarette use among youths as a means to help limit marijuana use in this population.