How Cannabis and Tobacco Are Used Together in Spain — and What Withdrawal Looks Like | Research

The takeaway

Among Spanish cannabis users seeking treatment, 88% mixed cannabis with tobacco, 76% experienced withdrawal symptoms, and women reported more severe withdrawal — with two distinct user profiles emerging.

Addiction treatment providers in European contexts, researchers studying dual cannabis-tobacco dependence, anyone who mixes cannabis and tobacco.

What the researchers found

This cross-sectional study of 94 participants entering cannabis use disorder treatment in Catalonia, Spain, documented the deeply intertwined nature of cannabis and tobacco use in a European context where mixing the two substances in "spliffs" is the dominant consumption method.

Daily tobacco use was reported by 91.5% of participants, with a mean Fagerström nicotine dependence score of 4.2 out of 10 (moderate dependence). Most participants (88.1%) co-used cannabis with tobacco in the same product. Cannabis withdrawal symptoms were experienced by 75.8%, with women reporting greater severity than men.

Cluster analysis revealed two distinct user profiles. Cluster 1 (71% of participants) represented one behavioral pattern, while Cluster 2 (29%) represented another — suggesting that cannabis-tobacco dual users are not a homogeneous group and may need different treatment approaches.

The findings highlight a complication that's particularly relevant in European cannabis culture: when cannabis and tobacco are co-administered in every use episode, quitting cannabis also means confronting nicotine withdrawal, and vice versa.

Why it matters

The European pattern of mixing cannabis with tobacco in spliffs creates a dual dependence that's different from the North American pattern of using cannabis alone. Treatment programs designed for cannabis alone may miss the tobacco component, and tobacco cessation programs may not account for the cannabis dimension. Understanding these co-use patterns is essential for effective treatment in populations where mixing is the norm.

The numbers in context

94 participants. Daily tobacco use: 91.5%. Mean Fagerström score: 4.2/10. Cannabis-tobacco co-use: 88.1%. Cannabis withdrawal: 75.8% experienced symptoms. Women reported greater withdrawal severity. Two behavioral clusters: Cluster 1 (71%), Cluster 2 (29%).

How the study worked

Cross-sectional study in substance use treatment programs in Catalonia, Spain. 94 participants initiating CUD treatment. Questionnaire assessing sociodemographics, cannabis and tobacco use characteristics, nicotine dependence (Fagerström), motivation to quit, and cannabis withdrawal symptoms. Hierarchical cluster analysis using Gower's distance to identify behavioral profiles.

Who was studied

N=94 participants aged 15-64, 50% female, from substance use treatment programs in Catalonia, Spain.

What this study cannot tell us

Cross-sectional design from a single treatment setting in Catalonia. The 94-participant sample is modest. Treatment-seeking individuals may not represent all dual users. European spliff culture differs from North American consumption patterns, limiting generalizability. Self-reported use measures may be imprecise.

How to read the evidence

Cross-sectional study from a treatment-seeking population — provides useful descriptive data on co-use patterns and withdrawal but cannot establish causal relationships.

When this study was published

Published in 2026, documenting current cannabis-tobacco co-use patterns in a European treatment context.

The bigger picture

This connects to the prenatal cannabis-tobacco review (RTHC-00239), which examined how both substances affect fetal development through overlapping epigenetic mechanisms. It also links to the cannabis withdrawal literature (RTHC-00037, RTHC-00249) by adding the complication of concurrent nicotine withdrawal. The finding that women experience more severe withdrawal echoes sex differences documented across multiple studies in this database (RTHC-00222, RTHC-00236, RTHC-00252).

Replication

Not stated in abstract.

Funding

Not reported in abstract.

Conflicts of interest

Not reported in abstract.

Questions still open

Should cannabis treatment programs in spliff-culture countries include formal tobacco cessation components? Do the two user profiles identified by cluster analysis require different treatment strategies? Why do women experience more severe cannabis withdrawal — is this biological or related to different use patterns?

Read the original research

Consumption patterns and withdrawal symptoms in dual cannabis-tobacco users in Spain: Cross-sectional study.

Addictive behaviors reports, 23, 100656

Addictive Behaviors Reports is a peer-reviewed journal focused on addiction research.

View on PubMed ↗Publisher’s paper ↗

Citation

Saura, Judith; Enríquez, Marta; Feliu, Ariadna; Roca, Xavier; Mondón, Silvia; Barrio, Pablo; Andreu, Magalí; Segura, Lidia; Ballbè, Montse; Fu, Marcela; Fernández, Esteve; Martínez, Cristina. (2026). Consumption patterns and withdrawal symptoms in dual cannabis-tobacco users in Spain: Cross-sectional study.. Addictive behaviors reports, 23, 100656. https://doi.org/10.1016/j.abrep.2025.100656