Cannabis use patterns among American Indian and Alaska Native adults across U.S. state cannabis policy environments

Cannabis legalization has expanded rapidly across the United States, yet little is known about how cannabis use patterns vary across state policy environments among American Indian/Alaska Native (AI/AN) adults. We examined whether cannabis use and frequency differed across state cannabis policy environments.

We analyzed 2022 Behavioral Risk Factor Surveillance System marijuana module data from 22 states, restricted to respondents classified as AI/AN (N = 1723). States were categorized as no legal cannabis, medical-only legal cannabis, or recreational legal cannabis. Outcomes were current cannabis use (any past-30-day use) and frequency (days used among current users). Analyses incorporated survey design and stabilized inverse probability of treatment weighting, with additional covariate adjustment for sex, age, education, income, marital status, and employment.

Overall, 22.0% (95% CI: 18.8%, 25.2%) reported current cannabis use. Weighted prevalence of current cannabis use was 17.97% in no-legal states, 24.01% in medical-only states, and 21.80% in recreational states. In the full sample, adjusted odds ratios for current cannabis use were not statistically different between respondents in medical-only or recreational states and those in no-legal-cannabis states. Cannabis use frequency among current users was higher in medical-only (IRR = 1.32, 95% CI: 1.09-1.60) and recreational states (IRR = 1.28, 95% CI: 1.02-1.61) relative to no-legal states. Stronger associations were observed in state-context analyses, particularly in states with federally recognized tribes and states with higher AI/AN sample representation.

Among AI/AN adults, statistically significant differences across state cannabis policy environments were observed for cannabis use frequency, but not for current use prevalence. Associations were stronger in selected state contexts.