The legalization of cannabis and the commencement of its retail sales in the United States have been linked to a rise in recreational use and concurrent use of tobacco, according to a new analysis of health behavioral data. Published in the journal Tobacco Control, the study also notes a decline in sole tobacco use.
This trend is particularly noticeable in higher-risk groups, such as individuals with poor mental health, as well as demographics historically less likely to use cannabis recreationally, including older adults and those with higher educational levels.
Shifts in Substance Use Patterns
The concurrent use of tobacco and cannabis is associated with a heightened risk of dependence, and emerging research suggests that this combination may have more severe health impacts than the use of either substance alone. Since 2012, several U.S. states have legalized cannabis for recreational use. By July 2025, 24 states plus the District of Columbia had legalized it for adults aged 21 and over. This legislative shift has coincided with increased adult cannabis use and a general decline in tobacco use.
However, whether these legal changes have prompted a rise in concurrent or sole tobacco use remains unclear. To explore this, researchers analyzed data from the annual Behavioral Risk Factor Surveillance System, managed by the Centers for Disease Control and Prevention (CDC) and state health departments.
Data Analysis and Findings
The study included data from 874,084 respondents aged 18 and older across 38 states that inquired about cannabis use from 2016 through 2023, with an average annual response rate of 44% to 50%. After excluding incomplete responses, the final analysis encompassed 854,878 adults.
Participants reported their cannabis use over the past 30 days and separately indicated their frequency of tobacco and vape use. Researchers categorized responses into four groups: no use, tobacco use only, cannabis use only, and concurrent use of both substances.
The prevalence of sole tobacco use varied from 8% in Massachusetts to 26% in West Virginia, while sole cannabis use ranged from just over 3% in West Virginia to 14% in Vermont. Concurrent use of tobacco and cannabis ranged from just over 3% in Utah to 9.5% in Alaska.
From 2016 to 2023, sole tobacco and cannabis use remained relatively stable at 14% and 7%, respectively, while concurrent use increased from just over 4% to just under 5.5%.
Demographic Insights and Trends
Overall, the patterns indicated greater use of either substance or concurrent use among higher-risk groups: younger adults, males, singles, those with lower education levels, uninsured individuals, and those reporting poor mental health and heavy drinking.
After legalization, the likelihood of sole cannabis use and concurrent use increased by 88% and 44%, respectively, while sole tobacco use decreased by 13%.
Sole cannabis use rose across all age groups, with the largest increases among 18–24-year-olds at just over 6% and those aged 65 and older at 2.5%. Other demographic shifts included a larger decline in sole tobacco use among women compared to men and a rise in cannabis use among adults with at least a high school education from just over 3.5% to just under 5%.
Concurrent use of both substances rose from nearly 1% to around 2%, and sole cannabis use increased among adults identifying as White, Black, Hispanic, and Other, rising from nearly 3% to 4.5%.
Implications and Future Considerations
Further analysis revealed that retail sales have contributed to increases in sole cannabis use and concurrent use of tobacco and cannabis. However, as an observational study, it cannot definitively establish causality, and researchers acknowledge several limitations, including the reliance on self-reported data and the exclusion of 12 states from the analysis.
Despite these limitations, the findings suggest a shift in product use in response to cannabis legalization. “Our findings add to growing evidence that adults are shifting product use in response to cannabis legalization,” the researchers noted.
“These shifting patterns may be narrowing disparities in use due to rising levels among populations less likely to use cannabis rather than declining use among higher-risk groups,” they concluded.
The study warns that changes in policy, increased access to cannabis products, and evolving public perceptions of cannabis safety could lead to increased co-use of tobacco and cannabis, even as tobacco use faces downward pressure from policy restrictions.
