Recreational cannabis legalization alters associations among cannabis use, perception of risk, and cannabis use disorder treatment for adolescents and young adults

Expanding legalization of recreational cannabis in the US represents a growing public health challenge (Leung et al., 2019). There are legitimate reasons for recreational cannabis legalization, such as potential therapeutic uses (Hill, 2019) and social justice concerns about the criminalization of cannabis use, including the racial and ethnic discrimination associated with legal sanctions (Adinoff & Reiman, 2019). However, long term and frequent cannabis use is associated with numerous negative health outcomes, including psychosis, mood disorders, and impaired cognitive function (Hasin and Walsh, 2021, Lovell et al., 2020, Onaemo et al., 2021), although direct causal evidence of such outcomes is unclear (Ganesh & D’Souza, 2022). Frequent cannabis use is also associated with cannabis use disorder (CUD) (Robinson et al., 2022), a condition marked by an inability to reduce or stop cannabis use even when causing harm (Connor et al., 2021), with a recent meta-analysis reporting the prevalence of CUD among those using cannabis at 22 % (Leung et al., 2020), putting millions of cannabis users at risk.

The legalization and commercialization of cannabis is associated with risk factors for CUD, including easier access to cannabis, stronger cannabis potency, greater variety of cannabis products, and exposure to cannabis advertising and sales (Chiu et al., 2021, D’Amico et al., 2018, Smart and Pacula, 2019). Of particular concern is the impact of recreational cannabis legalization on CUD prevalence for adolescents (age 12–17) and young adults (age 18–25), age groups particularly vulnerable to the negative health effects of sustained, frequent cannabis use (Chadi et al., 2018, Hines et al., 2020). Young adults in the US have the highest rate of CUD as compared to all age groups (Substance Abuse and Mental Health Services Administration, 2021), and developing CUD is more likely when cannabis use is initiated earlier in adolescence (Richter et al., 2017), with more than 20 % of adolescents developing CUD within four years of beginning cannabis use (Han et al., 2019). Young adult cannabis use and CUD prevalence have risen since the early 2000s (Hasin et al., 2019), and the perception of cannabis use as harmful has declined substantially among both adolescents and young adults (Sarvet et al., 2018, Wen et al., 2019), trends which evidence suggests have increased following cannabis legalization (Cerdá et al., 2020, Leung et al., 2019, Smart and Pacula, 2019).

Given these increasing risk factors for CUD, one might expect that CUD treatment utilization for adolescents and young adults would also be increasing. However, evidence indicates that since the middle 2000s, adolescent and young adult CUD treatment admissions in the US have fallen (Mennis, 2020, Mennis and Stahler, 2020, Standeven et al., 2020, Rhee and Rosenheck, 2022). Indeed, our prior research showed that from 2008 to 2017 states with greater increases in young adult cannabis use prevalence actually had greater declines in CUD treatment admissions (Mennis et al., 2021), a counterintuitive pattern that descriptive statistics suggested was stronger in states legalizing recreational cannabis.

We theorize that recreational cannabis legalization may induce changes in the conventional directionality of associations between lower perception of risk of harm from cannabis use and higher cannabis use prevalence (Hasin et al., 2019, Parker and Anthony, 2018, Taylor et al., 2019), as well as between higher cannabis use prevalence and higher CUD prevalence (Han et al., 2019, Leung et al., 2020), which may explain the observed decline in CUD treatment admissions during a period of increasing risk factors for CUD in the US. To our knowledge, no prior research has investigated how recreational cannabis legalization may affect such associations among CUD risk factors and treatment. In the present research we address this gap by investigating the following research questions regarding the effects of recreational cannabis legalization in the US from 2008 to 2019, for both adolescents and young adults:

1.

Did the prevalence of past-month cannabis use, perception of risk of harm from cannabis use, and rate of CUD treatment admissions change following recreational cannabis legalization?

2.

Did the associations between a) perception of risk of harm from cannabis use and prevalence of past-month cannabis use and b) prevalence of past-month cannabis use and rate of CUD treatment admissions change following recreational cannabis legalization?

We expect to find that the positive association between perception of risk and prevalence of cannabis use was strengthened following recreational cannabis legalization, as greater accessibility to cannabis and other characteristics of legalization enable greater cannabis use among those who perceive a lower risk (Levy et al., 2021). We also expect that the positive association between prevalence of cannabis use and CUD treatment admissions was weakened following recreational legalization, as increasing social acceptance of cannabis use and decreasing perception of risk may suppress both the prevalence of CUD among cannabis users as well as perception of treatment need among those with CUD (Askari et al., 2021, Compton et al., 2019). Such findings can enhance understanding of how recreational legalization may impact CUD prevalence and inform public health strategies for CUD prevention and treatment.

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