Cannabis and tobacco use among adolescents aged 12-17 years from 16 low- and middle-income countries

Background We aimed to examine the association between cannabis use and tobacco use in 12-17-year-old adolescents residing in low-and middle-income countries (LMICs).Methods We used data from the Global School-based Student Health Survey collected between 2012 and 2022. We selected 16 LMICs based on pre-defined inclusion criteria and compared the prevalence of cannabis use for female and for male adolescents for each country. We estimated age-and sex-standardised distributions of tobacco use, school truancy, suicide attempt, sex with multi-ple partners, physical fighting, perceived school kindness, and parental mon-itoring were estimated. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) measuring associations between cannabis use and other variables. We generated pooled estimates through random effects meta-analyses.Results The overall pooled prevalence of cannabis use was 4.3% (95% CI = 3.2-5.9), with significant between-country heterogeneities (I2= 91.4%; P= 0.000). Cannabis use was more prevalent in males than in females in each country. Tobacco use was strongly associated with cannabis use in all 16 LMICs. Tobac-co users had approximately 11 to 14 times greater odds of cannabis use than non-tobacco users. Sex with multiple partners, suicide attempts, and school truancy had a robust association with cannabis use in over half of LMICs.Conclusions There is a need for comprehensive preventive measures target-ing multiple risk behaviours associated with cannabis use for adolescents in LMICs.