Addiction. 2026 May 26. doi: 10.1111/add.70474. Online ahead of print.
ABSTRACT
BACKGROUND AND AIMS: With expanding cannabis legalization, normalization, and diversifying products and delivery methods in the United States (US), cannabis use disorder (CUD) prevalence is rising. Various modes of cannabis use may influence pharmacokinetics, usage patterns, and harm, affecting CUD risk. We measured associations between modes of cannabis use, including multi-modal patterns, and CUD prevalence and severity.
DESIGN AND SETTING: This cross-sectional study analyzed data from a nationally representative sample of US adults using the 2022-2023 National Survey on Drug Use and Health (NSDUH) data. Multivariable logistic regression analyses were employed to estimate the association between modes of cannabis use and past-year CUD, adjusting for potential confounders and covariates. Analyses were stratified by sex, age, and cannabis use frequency. Among multi-modal users, common combinations and their associations with CUD were further examined.
PARTICIPANTS/CASES: Respondents 18 years or older who reported past-year cannabis use (unweighted n = 25 549; weighted N = 58 850 309).
MEASUREMENTS: Exposure of interest was the mode of cannabis use, primarily categorized as smoke-only, vape-only, oral/mucosal-only, dab-only, topicals-only, and multi-modal (≥ two modes). The outcome variable was CUD in the past year, and CUD severity, based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Covariates included age, sex, race/ethnicity, income, education, state cannabis law status, age of cannabis initiation, cannabis use motive, frequency of use, perceived risk of smoking cannabis, illicit drug use, past year mental illness, nicotine dependence, and alcohol use disorder.
FINDINGS: Of the total past-year cannabis users, 53.9% reported multi-modal cannabis use. Overall, CUD prevalence was 30.3%, ranging from 4.4% among oral/mucosal-only to 40.5% among multi-modal, and 28.9% among dab-only users (p < 0.0001). Moderate-to-severe CUD affected 13.2% of all users and was concentrated among multi-modal and dab-only users. In multivariable regression, multi-modal users had fourfold higher odds of CUD (adjusted odds ratio [AOR] = 4.14; 95% confidence interval [CI]: 2.91-5.90). Elevated odds were also observed among smoke-only (AOR = 2.98; 95% CI: 2.02-4.39) and vape/dab-only users (AOR = 1.89; 95% CI: 1.09-3.29), compared with oral/mucosal-only users. Analyses of multi-modal combinations showed the highest CUD odds among those using smoke + vape + oral/mucosal + dab (AOR = 19.74; 95% CI: 9.11-42.75), compared with oral/mucosal + topicals users.
CONCLUSIONS: In the United States, modes of cannabis use appear to be statistically significantly associated with prevalence and severity of cannabis use disorder, with multi-modal and inhaled routes conferring the greatest risk. Findings underscore the importance of considering mode of use alongside frequency and potency in clinical assessment, prevention, and policy strategies aimed at reducing cannabis-related harms.
PMID:42186749 | DOI:10.1111/add.70474
