The legalization of recreational cannabis in the United States has ushered in a nuanced transformation in patterns of substance use, revealing complex interplays between cannabis and tobacco consumption. A comprehensive analysis published in the esteemed journal Tobacco Control sheds light on how these shifts manifest across different demographics and risk strata. This study harnessed data spanning from 2016 through 2023, capturing a pivotal period during which recreational cannabis became legally accessible to adults in numerous states, alongside the introduction of licensed retail outlets.
Examining data from over 850,000 adults in 38 states—including those that have legalized recreational cannabis—the investigators utilized responses from the Behavioral Risk Factor Surveillance System, a robust, annual health behavior survey administered by the Centers for Disease Control and Prevention. Respondents reported their cannabis and tobacco use frequencies over the preceding 30 days, allowing classification into distinct groups: users of neither substance, those using tobacco only, cannabis only, and those using both concurrently.
Statistical analysis reveals a fascinating trend: while sole tobacco and sole cannabis use remained relatively stable—hovering around 14% and 7%, respectively—the concurrent use of tobacco and cannabis has shown a modest but consistent increase, rising from just over 4% to nearly 5.5%. This uptick in co-use raises significant public health concerns given existing evidence that simultaneous consumption exacerbates risks of dependency and may potentiate adverse health outcomes beyond those observed with either substance alone.
The temporal association of these trends with cannabis legalization is of particular note. Post-legalization, the odds of exclusive cannabis use rose by 88%, and concurrent use with tobacco increased by 44%, albeit with a corresponding 13% decline in tobacco-only use. This suggests a substitution and convergence effect in substance use behaviors. Importantly, these dynamics vary substantially across demographic sectors. Young adults (18–24 years) exhibited the largest increases in cannabis use, exceeding 6%, while notable rises were also documented among older adults aged 65 and above—a demographic traditionally characterized by lower rates of cannabis consumption.
Further dissection illustrates that cannabis use escalated among individuals with at least a high school education, a group previously exhibiting lower recreational cannabis engagement. Concurrently, the prevalence of dual substance use also rose in this more educated cohort. In contrast, tobacco use declined more sharply among women compared to men, illuminating gender-specific trajectories in response to policy shifts.
Crucially, mental health emerges as a significant modifier of these trends. Adults reporting poor mental health experienced larger increases in cannabis use and concurrent use behaviors, aligning with prior literature linking substance use patterns with psychological distress. Conversely, this group also showed a more pronounced decline in tobacco-only use, hinting at complex substitution dynamics that warrant further mechanistic exploration.
Geographical disparities also underscore the variability in substance use prevalence. States such as Massachusetts reported sole tobacco use as low as 8%, whereas West Virginia observed rates exceeding 26%. Meanwhile, concurrent tobacco and cannabis use ranged widely, from approximately 3% in Utah to 9.5% in Alaska. These observations highlight the contextual influence of local culture, policy environment, and retail accessibility on consumption behaviors.
The introduction of licensed recreational cannabis retail outlets further intensified trends toward increased cannabis and concurrent use. Availability and normalization of cannabis products through these channels likely facilitate higher consumption, amplified by shifts in public perception about cannabis safety. However, despite these associations, causality cannot be definitively established due to the observational nature of the study and intrinsic limitations of the dataset, including reliance on self-reported data and incomplete coverage of all states.
It is worth noting that the data collection tool—the Behavioral Risk Factor Surveillance System—does not capture critical variables such as the method, timing, or frequency of simultaneous substance use, constraining in-depth behavioral analyses. Additionally, the average response rates per state ranged between 44% and 50%, introducing potential nonresponse bias which may skew prevalence estimates.
Despite these constraints, the study contributes substantially to a growing corpus of evidence suggesting that cannabis legalization and expanded retail access transform patterns of substance use. These changes potentially narrow historical disparities in cannabis use by elevating consumption among groups less traditionally inclined to use, rather than reflecting declines among higher-risk populations. This realignment has profound implications for public health surveillance, prevention strategies, and regulatory frameworks.
The authors caution that ongoing policy evolution demanding increased cannabis access intersects with persistent tobacco control measures, presenting a paradox where tobacco use declines even as co-use with cannabis rises. This suggests multifactorial pathways influenced by legal, social, and individual determinants, warranting multidisciplinary investigative approaches to unravel underlying mechanisms.
In conclusion, as states continue to legalize and commercialize recreational cannabis, a vigilant eye must be kept on the intertwined epidemiology of cannabis and tobacco use. Balanced public health responses need to consider the complexities of polysubstance use, the evolving socio-legal landscape, and demographic disparities to mitigate potential increases in dependence and adverse health consequences linked to concurrent substance consumption.
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Subject of Research: People
Article Title: Associations between recreational cannabis legalisation and disparities in use and co-use of tobacco and cannabis
News Publication Date: 9-Feb-2026
Web References:
– Behavioral Risk Factor Surveillance System (BRFSS): https://www.cdc.gov/brfss/index.html
– DOI of the article: http://dx.doi.org/10.1136/tc-2025-059748
Keywords: Cannabis, Tobacco, Legislation
