With the ongoing opioid epidemic now in its fourth wave (Ciccarone, 2021) and high morbidity and mortality due to cigarette smoking (U.S. Department of Health and Human Services et al., 2020), it is critical to understand how population-level interactions between opioid misuse and cigarette smoking might best inform public health programs. People who smoke cigarettes experience disparities in opioid misuse and related consequences (Parker et al., 2018). Individuals with versus without cigarette use have been estimated to be at least twice as likely to misuse opioids (Parker and Villanti, 2019, Zale et al., 2015) and smoking prevalence is much higher for persons with versus without opioid misuse (65% versus 26%; Parker et al., 2020). The combination of nicotine and opioid misuse leads to an increased risk of premature mortality compared to use of either substance alone (Kertesz et al., 2012).

The strong relationship between opioids and nicotine may be due to the overlapping and long-lasting effects of nicotine and opioids in the brain (Hadjiconstantinou and Neff, 2011, Kishioka et al., 2014). Treatment of nicotine to the brain may sensitize and augment the reinforcing effects of opioids (Vihavainen et al., 2008) and tolerance and/or withdrawal can happen from chronic exposure to nicotine or opioids (Kohut, 2017). Nicotine depresses the central nervous system and may also decrease the effects of opioids (e.g., reduced pain relief) (National Institute on Drug Abuse, 2018).

Efforts to understand factors related to opioid misuse initiation are critical to reduce opioid misuse and the harms of opioid misuse across the lifespan as the peak risk of first opioid misuse and transition from initiation to opioid use disorder are seen in mid-adolescence (Parker and Anthony, 2015). The number of overall past year initiates of opioid misuse has declined from 2.1 million people in 2015 to 1.6 million people in 2019 in the United States (US) (United States, 2020) but it is not clear that this decline has been the same for those who are particularly vulnerable to opioid misuse such as people using cigarettes. As described above, there is a connection between cigarette use and opioid use, and cigarette use has been linked to the initiation of use or misuse of other substance (e.g., Weinberger et al., 2017); however, research has not yet examined the association of cigarette use with opioid misuse incidence.

The aim of this study was to determine the incidence of opioid misuse for US individuals who currently or formerly smoked cigarette versus never smoked. We hypothesized that opioid misuse incidence would be most likely for persons who currently smoked followed by those who formerly smoked and both would be higher than the incidence of those who never smoked. Due to the increasing prevalence of electronic cigarette (e-cigarettes/vaping) use among youth and young adults (United States Department of Health and Human Services, 2016) and the documented association between e-cigarettes and opioid misuse (e.g., Conway et al., 2017, Parker and Villanti, 2019), an exploratory aim investigated differences in opioid misuse for persons who ever vaped nicotine and those who vaped nicotine recently.