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Original Investigation
March 2018

Association of Combined Patterns of Tobacco and Cannabis Use in Adolescence With Psychotic Experiences

Author Affiliations
  • 1Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
  • 2Medical Research Centre, Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
  • 3Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom
  • 4Division of Psychiatry, University College London, London, United Kingdom
  • 5UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, United Kingdom
  • 6MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, United Kingdom
JAMA Psychiatry. 2018;75(3):240-246. doi:10.1001/jamapsychiatry.2017.4271
Key Points

Question  Are patterns of adolescent cigarette and cannabis use differentially associated with subsequent onset of psychotic experiences?

Findings  In this longitudinal cohort study of 3328 adolescents, there is evidence that both cannabis and cigarette use are associated with subsequent psychotic experiences prior to adjusting for confounders. However, after adjusting, the associations for cigarette-only use attenuated substantially, whereas those for cannabis use remained consistent.

Meaning  While individuals who use either cannabis or cigarettes during adolescence appear to be at increased risk of psychotic experiences, the association of psychotic experiences is greater with cannabis than with tobacco smoking.


Importance  There is concern about potentially causal effects of tobacco use on psychosis, but epidemiological studies have been less robust in attempts to minimize effects of confounding than studies of cannabis use have been.

Objectives  To examine the association of patterns of cigarette and cannabis use with preceding and subsequent psychotic experiences, and to compare effects of confounding across these patterns.

Design, Setting, and Participants  This cohort study used data from the Avon Longitudinal Study of Parents and Children, which initially consisted of 14 062 children. Data were collected periodically from September 6, 1990, with collection ongoing, and analyzed from August 8, 2016, through June 14, 2017. Cigarette and cannabis use data were summarized using longitudinal latent class analysis to identify longitudinal classes of substance use. Associations between classes and psychotic experiences at age 18 years were assessed.

Exposures  Depending on the analysis model, exposures were longitudinal classes of substance use or psychotic experiences at age 12 years.

Main Outcomes and Measures  Logistic regression was used to examine the associations between substance use longitudinal classes and subsequent onset of psychotic experiences.

Results  Longitudinal classes were derived using 5300 participants (56.1% female) who had at least 3 measures of cigarette and cannabis use from ages 14 to 19 years. Prior to adjusting for a range of potential confounders, there was strong evdience that early-onset cigarette-only use (4.3%), early-onset cannabis use (3.2%), and late-onset cannabis use (11.9%) (but not later-onset cigarette-only use [14.8%]) latent classes were associated with increased psychotic experiences compared with nonusers (65.9%) (omnibus P < .001). After adjusting for confounders, the association for early-onset cigarette-only use attenuated substantially (unadjusted odds ratio [OR], 3.03; 95% CI, 1.13-8.14; adjusted OR, 1.78; 95% CI, 0.54-5.88), whereas those for early-onset cannabis use (adjusted OR, 3.70; 95% CI, 1.66-8.25) and late-onset cannabis use (adjusted OR, 2.97; 95% CI, 1.63-5.40) remained consistent.

Conclusions and Relevance  In this study, our findings indicate that while individuals who use cannabis or cigarettes during adolescence have an increased risk of subsequent psychotic experiences, epidemiological evidence is substantively more robust for cannabis use than it is for tobacco use.