Changing Norms, Changing Risks: Adolescent Cannabis Use Surpasses Tobacco in the United States

Background Rapid expansion of adult-use cannabis legalization in the U.S. altered adolescents’ exposure to and perceptions of cannabis risk. Early initiation of cannabis use may increase dependence vulnerability and long-term health consequences, echoing early tobacco diffusion before its harms were fully recognized. This study examines national trends in tobacco and cannabis use and co-use among U.S. adolescents, identifying demographic groups experiencing most pronounced shifts. Methods Using nationally representative data from 2015 to 2023 National Survey on Drug Use and Health, we assessed past-30-day cannabis-only use, tobacco-only (cigarettes, cigars, pipes, and smokeless tobacco) use, and co-use among adolescents aged 12–17. Trends were examined across pre-pandemic (2015–2019), pandemic onset (2020), and post-pandemic (2021–2023) periods. Multivariable logistic regression models estimated sociodemographic predictors. Results Cannabis-only use predominated throughout the study period, increasing from 3.8% in 2015 to 5.1% in 2023. Conversely, tobacco-only use and co-use declined. Largest increase in cannabis-only use and sharpest decline in tobacco-only use occurred among older adolescents (16–17), consistently exhibiting higher probabilities of cannabis-only use than younger adolescents (AMEs between 10.9–16.0 percentage-points). Post-pandemic, Medicaid-insured adolescents were significantly more likely than privately insured peers to use cannabis-only (AME = 1.1 percentage-points; 95% CI: 0.1, 2.0). Conclusion Cannabis use prevalence surpassed tobacco use prevalence as the dominant substance among U.S. adolescents. These patterns resemble tobacco uptake in early stages, underscoring the urgency of recalibrating youth prevention strategies. As cannabis policy continues to evolve, public health responses must prioritize adolescent-focused risk communication, integrate cannabis prevention into existing tobacco control infrastructures, and anticipate long-term population health consequences.