Compared to those who reported a lifetime co-occurrence of cannabis and tobacco use, individuals who report simultaneous use of cannabis and tobacco are more likely to also report higher rates of substance-related problems and psychopathology. In a sample of young women, we examine (a) co-occurring use, or whether regular cigarette smoking is associated with increased cannabis involvement and (b) simultaneous use, a special form of co-occurring use where cannabis and cigarettes are typically used on the same occasion to test whether those who use cannabis and tobacco simultaneously are also more likely to report greater cannabis involvement and (c) the extent to which latent genetic and environmental factors contribute to simultaneous use in those with a history of co-occurring cannabis use and regular cigarette smoking. Women (N=3427) who report regular cigarette smoking are 4.5-9.5 times more likely to report co-occurring cannabis use and other stages of cannabis involvement, including DSM-IV cannabis abuse and dependence. In those women who report co-occurring regular cigarette smoking and lifetime cannabis use (N=1073), simultaneous use of cannabis and tobacco was associated with increased likelihood of negative cannabis-related outcomes. Simultaneous users were 1.6 times more likely to meet criteria for DSM-IV cannabis abuse, even after controlling for early covariates and for prior stages of cannabis involvement. Simultaneous use was not heritable, and twin similarity was attributable to shared environmental factors (31%). While our study does not determine causality between simultaneous tobacco-cannabis use and cannabis involvement, results indicate that simultaneous use is potentially a marker for more severe psychosocial consequences associated with cannabis use.