Cannabis Legalization Drives Up Tobacco-Cannabis Co-Use While Reducing Tobacco-Only Use
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.
Quick Facts
What This Study 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.
Key Numbers
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 They Did This
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.
Why This Research 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 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.
What This Study Doesn't 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.
Questions This Raises
- ?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?
Trust & Context
- Key Stat:
- Evidence Grade:
- Very large sample with quasi-experimental design, state/year fixed effects, and multiple sensitivity analyses provide strong evidence for these associations.
- Study Age:
- Published 2026; covers 2016-2023 across 38 US states.
- Original Title:
- Associations between recreational cannabis legalisation and disparities in use and co-use of tobacco and cannabis.
- Published In:
- Tobacco control (2026)
- Authors:
- Hawkins, Summer Sherburne(3), Baidoo, Christopher E(3), Centanni, Ryan S(3), Coley, Rebekah Levine, Baum, Christopher F
- Database ID:
- RTHC-08326
Evidence Hierarchy
Frequently Asked Questions
Does cannabis legalization affect tobacco use?
Yes — legalization decreased tobacco-only use by 13%, but simultaneously increased tobacco-cannabis co-use by 44%, creating a more complex public health picture.
Who starts co-using tobacco and cannabis after legalization?
Co-use increases were observed among adults aged 18-24 and 55+, those with at least a high school education, and White and Black adults — populations that previously had lower cannabis use rates.
Read More on RethinkTHC
Cite This Study
https://rethinkthc.com/research/RTHC-08326APA
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
MLA
Hawkins, Summer Sherburne, et al. "Associations between recreational cannabis legalisation and disparities in use and co-use of tobacco and cannabis.." Tobacco control, 2026. https://doi.org/10.1136/tc-2025-059748
RethinkTHC
RethinkTHC Research Database. "Associations between recreational cannabis legalisation and ..." RTHC-08326. Retrieved from https://rethinkthc.com/research/hawkins-2026-associations-between-recreational-cannabis
Access the Original Study
Study data sourced from PubMed, a service of the U.S. National Library of Medicine, National Institutes of Health.
This study breakdown was produced by the RethinkTHC research team. We analyze and report published research findings without making health recommendations. All interpretations are based solely on the published abstract and study data.