Documented Nicotine, Cannabis, and Co-Use Are Associated With More Intensive Emergency Department Care for Adolescent Asthma Exacerbations

Objectives Asthma exacerbations pose substantial risk to adolescents. We evaluated whether documented nicotine use, cannabis use, or concurrent use is associated with increased emergency department (ED) management intensity and adverse short-term outcomes during asthma exacerbations. Methods Using the TriNetX database, we identified adolescents aged 11 to 21 years presenting to the ED with an acute asthma exacerbation from January 1, 2015, to January 1, 2025. Patients were categorized into nicotine-only, cannabis-only, or concurrent nicotine-cannabis cohorts based on documented International Classification of Diseases, 10th Revision (ICD-10) codes and matched to controls without such diagnoses. Outcomes were reported as risk ratios (RRs) with 95% CIs during 0 to 1-day and 1- to 30-day intervals. Results After matching, cohorts included 4604 nicotine-only, 2679 cannabis-only, and 1045 co-use patients. During their ED encounter, co-use patients demonstrated the strongest associations with acute respiratory failure (RR, 4.63; 95% CI, 2.71-7.89), hospital admission (RR, 2.47; 95% CI, 1.80-3.38), and critical care services (RR, 1.92; 95% CI, 1.19-3.09). Nicotine-only and cannabis-only cohorts also showed increased pharmacologic escalation and diagnostic testing. Between 1 and 30 days, co-use patients had higher rates of repeat exacerbation (RR, 1.72; 95% CI, 1.36-2.17), ED revisits (RR, 1.54; 95% CI, 1.29-1.85), pneumonia (RR, 2.20; 95% CI, 1.05-4.62), and critical care use (RR, 2.07; 95% CI, 1.10-3.90); nicotine-only and cannabis-only cohorts additionally demonstrated this association to a lesser degree. Conclusion Adolescents with documented nicotine or cannabis use, especially concurrent use, experience more intensive ED management and worse short-term outcomes during asthma exacerbations, supporting consideration of targeted acute care pathways.