Recreational cannabis legalization was associated with an 88% increase in cannabis-only use and a 44% increase in tobacco-cannabis co-use, while reducing tobacco-only use by 13% — with co-use rising among populations that historically had lower cannabis use.
Public health officials, cannabis policy makers, tobacco cessation programs, and researchers studying substance use trends post-legalization.
What the researchers found
Legalization increased cannabis-only use (aRRR=1.88, 95% CI=1.78-1.99) and tobacco-cannabis co-use (aRRR=1.44, 95% CI=1.34-1.54) compared to no use, while decreasing tobacco-only use (aRRR=0.87, 95% CI=0.83-0.91), with co-use increases observed among ages 18-24 and 55+, those with high school education+, and White and Black adults.
Why it matters
While legalization reduces tobacco-only use, the simultaneous increase in tobacco-cannabis co-use — which combines the health risks of both substances — represents an unintended consequence that public health responses must address.
The numbers in context
N=854,878; 38 states; 2016-2023; cannabis-only aRRR=1.88; co-use aRRR=1.44; tobacco-only aRRR=0.87; co-use increases among ages 18-24 and 55+, White and Black adults, those with HS degree+
How the study worked
Analysis of 2016-2023 BRFSS data from 854,878 adults in 38 states linked to recreational cannabis legalization status, using multinomial logit regression with demographic/policy controls and state/year fixed effects.
What this study cannot tell us
BRFSS is self-report and cross-sectional within years; co-use definition doesn't distinguish concurrent from simultaneous use; cannot determine if co-use replaces tobacco-only or represents new users; state-level variation in implementation.
How to read the evidence
Very large sample with quasi-experimental design, state/year fixed effects, and multiple sensitivity analyses provide strong evidence for these associations.
When this study was published
Published 2026; covers 2016-2023 across 38 US states.
The bigger picture
Cannabis legalization's net impact on public health depends on whether the reduction in tobacco-only use outweighs the increase in co-use — a question that requires long-term monitoring of health outcomes.
Questions still open
- Does co-use carry higher health risks than cannabis-only or tobacco-only use? Would targeted prevention for co-use mitigate the public health impact? Are there populations where legalization reduces all substance use?
Common questions
Does cannabis legalization affect tobacco use?
Who starts co-using tobacco and cannabis after legalization?
Read the original research
Associations between recreational cannabis legalisation and disparities in use and co-use of tobacco and cannabis.
Tobacco control
Citation
Hawkins, Summer Sherburne; Baidoo, Christopher E; Centanni, Ryan S; Coley, Rebekah Levine; Baum, Christopher F. (2026). Associations between recreational cannabis legalisation and disparities in use and co-use of tobacco and cannabis.. Tobacco control. https://doi.org/10.1136/tc-2025-059748