Recreational Marijuana Legalization and Co-use With Alcohol Among Adolescents


      Little is known about the possible impacts of recreational marijuana legalization on alcohol and marijuana co-use among underage youth. This study examines the association between recreational marijuana legalization in California in 2016 and alcohol and marijuana co-use among adolescents. Additional analyses investigate the associations between recreational marijuana legalization and co-use among past 30–day drinkers and marijuana users and the frequency of alcohol and marijuana use among co-users.


      This study used annual cross-sectional data from 7th, 9th, and 11th graders (N=3,319,329) who participated in the California Healthy Kids Survey from 2010–2011 to 2018–2019. Measures included past 30–day alcohol and marijuana use and student demographic characteristics, survey year, pre–post recreational marijuana legalization, and urbanicity. Multilevel regression analyses were conducted in 2021.


      Recreational marijuana legalization was associated with greater odds of past 30–day alcohol and marijuana co-use in the total sample (OR=1.06, 95% CI=1.05, 1.07). Recreational marijuana legalization was more strongly associated with co-use among adolescents who reported past 30–day alcohol use (OR=1.58, 95% CI=1.52, 1.62) and heavy drinking (OR=1.25, 95% CI=1.21, 1.29) but was inversely related to co-use among past 30–day marijuana users (OR=0.76, 95% CI=0.74, 0.78). Among past 30–day co-users, there was a positive association with the frequency of marijuana use (β=0.36, SE=0.07).


      Recreational marijuana legalization may increase the risk of alcohol and marijuana co-use among adolescents. Greater restrictions on the numbers of alcohol and marijuana retail outlets and hours of operation and advertising and higher taxes on alcohol and marijuana products may help reduce the availability of these substances to adolescents.
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        • National Conference of State Legislatures
        State medical marijuana Laws.
        National Conference of State Legislatures, Denver, COJuly 14, 2021 (PublishedAccessed July 22, 2021)
      1. Alcohol Policy Information System: recreational use of cannabis: volume 1. National Institute on Alcohol Abuse and Alcoholism, NIH. Accessed July 22, 2021.

      2. Laws and regulations: medicinal and adult use cannabis regulation and safety act . California Bureau of Cannabis Control. Accessed July 22, 2021.

        • Volkow ND
        • Baler RD
        • Compton WM
        • Weiss SR.
        Adverse health effects of marijuana use.
        N Engl J Med. 2014; 370: 2219-2227
        • Volkow ND
        • Swanson JM
        • Evins AE
        • et al.
        Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review.
        JAMA Psychiatry. 2016; 73: 292-297
        • Miech RA
        • Johnston L
        • O’Malley P
        • Bachman J
        • Schulenberg J
        • Patrick M
        Monitoring the future national survey results on drug use, 1975–2018: volume i, secondary school students.
        Institute for Social Research, University of Michigan, Ann Arbor, MIJune 1, 2019 (Accessed May 4, 2021)
        • Anderson DM
        • Hansen B
        • Rees DI
        • Sabia JJ.
        Association of marijuana laws with teen marijuana use: new estimates from the Youth Risk Behavior Surveys.
        JAMA Pediatr. 2019; 173: 879-881
        • Dilley JA
        • Richardson SM
        • Kilmer B
        • Pacula RL
        • Segawa MB
        • Cerdá M.
        Prevalence of cannabis use in youths after legalization in Washington State.
        JAMA Pediatr. 2019; 173: 192-193
        • Brooks-Russell A
        • Ma M
        • Levinson AH
        • et al.
        Adolescent marijuana use, marijuana-related perceptions, and use of other substances before and after initiation of retail marijuana sales in Colorado (2013-2015).
        Prev Sci. 2019; 20: 185-193
        • Paschall MJ
        • García-Ramírez G
        • Grube JW.
        Recreational marijuana legalization and use among California adolescents: findings from a statewide survey.
        J Stud Alcohol Drugs. 2021; 82: 103-111
        • Paschall MJ
        • Grube JW.
        Recreational marijuana availability in Oregon and use among adolescents.
        Am J Prev Med. 2020; 58: e63-e69
        • Sokolovsky AW
        • Gunn RL
        • Micalizzi L
        • White HR
        • Jackson KM.
        Alcohol and marijuana co-use: consequences, subjective intoxication, and the operationalization of simultaneous use.
        Drug Alcohol Depend. 2020; 212107986
        • Brière FN
        • Fallu JS
        • Descheneaux A
        • Janosz M.
        Predictors and consequences of simultaneous alcohol and cannabis use in adolescents.
        Addict Behav. 2011; 36: 785-788
        • Lipperman-Kreda S
        • Gruenewald PJ
        • Grube JW
        • Bersamin M.
        Adolescents, alcohol, and marijuana: context characteristics and problems associated with simultaneous use.
        Drug Alcohol Depend. 2017; 179: 55-60
        • Egan KL
        • Cox MJ
        • Suerken CK
        • et al.
        More drugs, more problems? Simultaneous use of alcohol and marijuana at parties among youth and young adults.
        Drug Alcohol Depend. 2019; 202: 69-75
        • Gunn RL
        • Norris AL
        • Sokolovsky A
        • Micalizzi L
        • Merrill JE
        • Barnett NP.
        Marijuana use is associated with alcohol use and consequences across the first 2 years of college.
        Psychol Addict Behav. 2018; 32: 885-894
        • Stevens AK
        • Aston ER
        • Gunn RL
        • et al.
        Examining the influence of alcohol and cannabis product combinations on simultaneous use and consequences in daily life.
        Alcohol Clin Exp Res. 2021; 45: 181-193
        • White HR
        • Kilmer JR
        • Fossos-Wong N
        • Hayes K
        • Sokolovsky AW
        • Jackson KM.
        Simultaneous alcohol and marijuana use among college students: patterns, correlates, norms, and consequences.
        Alcohol Clin Exp Res. 2019; 43: 1545-1555
        • Lee CM
        • Patrick ME
        • Fleming CB
        • et al.
        A daily study comparing alcohol-related positive and negative consequences for days with only alcohol use versus days with simultaneous alcohol and marijuana use in a community sample of young adults.
        Alcohol Clin Exp Res. 2020; 44: 689-696
        • Jackson KM
        • Sokolovsky AW
        • Gunn RL
        • White HR.
        Consequences of alcohol and marijuana use among college students: prevalence rates and attributions to substance-specific versus simultaneous use.
        Psychol Addict Behav. 2020; 34: 370-381
        • Linden-Carmichael AN
        • Stamates AL
        • Lau-Barraco C.
        Simultaneous use of alcohol and marijuana: patterns and individual differences.
        Subst Use Misuse. 2019; 54: 2156-2166
        • Yurasek AM
        • Aston ER
        • Metrik J.
        Co-use of alcohol and cannabis: a review.
        Curr Addict Rep. 2017; 4: 184-193
        • Risso C
        • Boniface S
        • Subbaraman MS
        • Englund A.
        Does cannabis complement or substitute alcohol consumption? A systematic review of human and animal studies.
        J Psychopharmacol. 2020; 34: 938-954
        • Pape H
        • Rossow I
        • Storvoll EE.
        Under double influence: assessment of simultaneous alcohol and cannabis use in general youth populations.
        Drug Alcohol Depend. 2009; 101: 69-73
        • García-Ramírez G
        • Paschall MJ
        • Grube JW.
        Retail availability of recreational marijuana and alcohol in Oregon counties and co-use of alcohol and marijuana and related beliefs among adolescents.
        Subst Use Misuse. 2021; 56: 345-352
      3. California school climate, health, and learning surveys. California Department of Education, CalSCHLS. Accessed July 22, 2021.

      4. DataQuest, California Department of Education. Accessed July 22, 2021.

      5. Rural urban continuum codes. USDA Economic Research Services, U.S. Department of Agriculture. Updated December 10, 2020. Accessed July 22, 2021.

        • Raudenbush S
        • Bryk A
        • Cheong YF
        • Congdon R
        • du Toit M.
        HLM 8: Hierarchical linear and nonlinear modeling.
        Scientific Software International, Lincolnwood, IL2019 (Accessed May 4, 2021.)
        • Morrison C
        • Gruenewald PJ
        • Freisthler B
        • Ponicki WR
        • Remer LG.
        The economic geography of medical cannabis dispensaries in California.
        Int J Drug Policy. 2014; 25: 508-515
        • Shih RA
        • Rodriguez A
        • Parast L
        • et al.
        Associations between young adult marijuana outcomes and availability of medical marijuana dispensaries and storefront signage.
        Addiction. 2019; 114: 2162-2170
        • Shi Y
        • Meseck K
        • Jankowska MM.
        Availability of medical and recreational marijuana stores and neighborhood characteristics in Colorado.
        J Addict. 2016; 20167193740
        • Miech R
        • Johnston L
        • O'Malley PM
        • Bachman JG
        • Patrick ME
        Trends in adolescent vaping, 2017-2019.
        N Engl J Med. 2019; 381: 1490-1491