Hannah Walsh is a mental health nurse, and a PhD candidate at the Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care at King’s College London.
In 2020 the National Centre for Smoking Cessation and Training (NCSCT) published a briefing about delivering smoking cessation services for people who used both cannabis and tobacco. The SSA talked to the first author Hannah Walsh
SSA: Who is this briefing for?
Hannah Walsh: The briefing is for smoking cessation practitioners who encounter people who also use cannabis. It is a guide for those practitioners who may, or may not, know much about cannabis, about how it might affect somebody’s chances of making a successful tobacco quit attempt. The idea is that it gives those practitioners a bit of background information as well as a helping provide a starting point for talking to their clients about cannabis use.
What issues do people who smoke both tobacco and cannabis face?
The most common way of consuming cannabis in this country is in a spliff or a joint. Typically, people roll cannabis with tobacco and smoke the two substances together. So, if you’re trying to stop smoking tobacco but are continuing to smoke spliffs, then you are still smoking tobacco. That maybe something that smokers are very aware of, it may be something that they’re aware of but don’t particularly want to think about. Or it may be something that hasn’t occurred to them.
One of the challenges is that, if you continue to smoke cannabis in the same way as you have done – i.e. in a joint or a spliff – then you are still consuming tobacco and that’s going to make it really difficult to quit smoking tobacco in cigarettes.
Is this different in the US and Canada where fewer people smoke tobacco and cannabis together?
Yes, potentially. The ways of consuming cannabis are quite different across the world. In the US they tend to smoke cannabis without tobacco; they might smoke it on its own rolled up in paper or they might use it in a vaporiser. I think a lot of cannabis consumers in the US find it a bit odd to want to put tobacco with cannabis.
There is some evidence from the US that an increasing number of cannabis users might also use tobacco, but separately. For example, people might use cannabis in a vaporiser and follow that very quickly with a cigarette in order to perhaps enhance the experience that they’ve got from the cannabis.
How should practitioners use this briefing?
It’s important to understand that we don’t yet have a lot of evidence about how best to help people quit tobacco in the context of cannabis use. But we are aware that many people who use both tobacco and cannabis and who attend stop smoking services either haven’t been asked about it or they haven’t found a useful way to address it.
Hopefully the briefing will give smoking cessation practitioners the confidence to ask about cannabis use, to help them know a bit more about cannabis and to feel more comfortable having those sorts of conversations.
The briefing outlines some of the issues around whether to make a complete quit attempt of both substances or whether to take a harm reduction approach and separate the tobacco from the cannabis. Some might consider switching the way they consume cannabis by trying a dry herb vaporiser or by switching to edibles.
A lot of people are familiar with the symptoms of nicotine withdrawal. What are the symptoms of cannabis withdrawal?
So, people may experience restlessness, agitation or difficulty sleeping. Cannabis is often used to aid sleep, so withdrawal from cannabis can cause difficulty sleeping. Someone may also experience a degree of irritability.
What is striking is that many cannabis withdrawal symptoms look very similar to tobacco withdrawal symptoms. So, somebody who is making a quit attempt of one or the other can find it quite difficult to work out which substance is causing which symptoms.
In the briefing you mention about COVID-19. What impact has that had your work?
The briefing was in the final stages when the pandemic hit. So, we wanted to add something in the briefing about COVID-19 because it’s clearly a huge issue for all of us. We are particularly interested in the patterns of cannabis use among people who smoke it as a social activity. So, we’ve added a few suggestions to encourage smoking cessation practitioners to ask their clients about how COVID-19 it has influenced their clients’ cannabis use.
There is also, of course, the huge issue of transmission. We don’t yet know enough about how COVID-19 is transmitted to be able to give definitive guidance. The obvious points are that if you share cannabis with other people, then that is likely to increase the risks of transmission. We also know a bit more now about the risks of being near to someone who is exhaling, smoke, or vapour, and we know that that might contain a degree of risk.
Where should people get in contact if they want to know more?
We’re really keen to hear about people’s experiences of using the briefing or people’s experiences of working with clients who also use cannabis, so please do get in touch with the NCSCT with any feedback. We are also interested in any feedback people might have from their own practice that could help us to update the briefing. This is the first briefing of its kind and it’s very much a starting point so we want to hear from people about what would be useful for future briefings.
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