Cannabis Use During Adolescence and Young Adulthood and Academic Achievement: A Systematic Review and Meta-Analysis

Olsen Chan; Ahad Daudi; David Ji; Mathias Wang; Jeremy P Steen; Parsia Parnian; Crystal Li; Annie Xiong; Wei Zhang; Luciane C Lopes; James MacKillop; Jason W Busse; Li Wang

doi:10.1001/jamapediatrics.2024.3674

. 2024 Oct 7;178(12):1280–1289. doi: 10.1001/jamapediatrics.2024.3674

Cannabis Use During Adolescence and Young Adulthood and Academic Achievement

A Systematic Review and Meta-Analysis

Olsen Chan ^1,², Ahad Daudi ², David Ji ², Mathias Wang ², Jeremy P Steen ^2,³, Parsia Parnian ², Crystal Li ², Annie Xiong ², Wei Zhang ⁴, Luciane C Lopes ⁵, James MacKillop ^6,⁷, Jason W Busse ^7,^8,^9,¹⁰, Li Wang ^8,^9,^10,^✉

¹Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

²Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

³Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

⁴McMaster University Library, McMaster University, Hamilton, Ontario, Canada

⁵Graduate Program in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil

⁶Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada

⁷Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada

⁸Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada

⁹Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada

¹⁰Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada

Accepted for Publication: July 17, 2024.

Published Online: October 7, 2024. doi:10.1001/jamapediatrics.2024.3674

^✉

Corresponding Author: Li Wang, PhD, Department of Anesthesia, McMaster University, MDCL 2113, 1280 Main St W, Hamilton, ON L8S 4K1, Canada (wangli1@mcmaster.ca).

Author Contributions: Mr Chan and Dr L. Wang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chan, L. Wang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Chan, Daudi, Li, L. Wang.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: L. Wang.

Administrative, technical, or material support: Chan, Ji, MacKillop, L. Wang.

Supervision: L. Wang.

Conflict of Interest Disclosures: Dr MacKillop reported receiving grants from the National Institutes of Health, Canadian Institutes of Health Research, and Health Canada, holding the Peter Boris Chair in Addictions Research and a Tier 1 Canada Research Chair in Translational Addiction Research, receiving personal fees from Clairvoyant Therapeutics, Inc, and serving as a principal/senior scientist for BEAM Diagnostics Inc outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We thank Rachel Couban, MA, MISt, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, for retrieval of some full-text articles. We also thank Jennifer Maggs, PhD, Department of Human Development and Family Studies, Pennsylvania State University, and Alfonso Mercado, PhD, University of Texas–Rio Grande Valley, for clarification of their study results. Last, we thank Nigar Sekercioglu, PhD, Department of Health Research Methods, Evidence, and Impact, McMaster University, for screening 2 Turkish articles and Vallen Lin, Faculty of Health Sciences, McMaster University, for assistance with the title and abstract screening. No financial compensation was provided to these individuals.

^✉

Corresponding author.

PMCID: PMC11459363 PMID: 39374005

Key Points

Question

What is the association between cannabis use during adolescence or young adulthood and academic achievement?

Findings

In this meta-analysis of 63 studies including 438 329 individuals, moderate-certainty evidence showed cannabis use during adolescence and young adulthood is probably associated with lower school grades; less likelihood of high school completion, university enrollment, and postsecondary degree attainment; and increased school dropout rate and school absenteeism. Low-certainty evidence suggested cannabis use may be associated with increased unemployment.

Meaning

Cannabis use during adolescence and young adulthood is associated with worse academic performance; further research is needed to mitigate upstream and downstream factors associated with early cannabis exposure.

Abstract

Importance

Cannabis use during adolescence and young adulthood may affect academic achievement; however, the magnitude of association remains unclear.

Objective

To conduct a systematic review evaluating the association between cannabis use and academic performance.

Data Sources

CINAHL, EMBASE, MEDLINE, PsycInfo, PubMed, Scopus, and Web of Science from inception to November 10, 2023.

Study Selection

Observational studies examining the association of cannabis use with academic outcomes were selected. The literature search identified 17 622 unique citations.

Data Extraction and Synthesis

Pairs of reviewers independently assessed risk of bias and extracted data. Both random-effects models and fixed-effects models were used for meta-analyses, and the Grading of Recommendations Assessment, Development, and Evaluation approach was applied to evaluate the certainty of evidence for each outcome. Data were analyzed from April 6 to May 25, 2024.

Main Outcomes and Measures

School grades, school dropout, school absenteeism, grade retention, high school completion, university enrollment, postsecondary degree attainment, and unemployment.

Results

Sixty-three studies including 438 329 individuals proved eligible for analysis. Moderate-certainty evidence showed cannabis use during adolescence and young adulthood was probably associated with lower school grades (odds ratio [OR], 0.61 [95% CI, 0.52-0.71] for grade B and above); less likelihood of high school completion (OR, 0.50 [95% CI, 0.33-0.76]), university enrollment (OR, 0.72 [95% CI, 0.60-0.87]), and postsecondary degree attainment (OR, 0.69 [95% CI, 0.62-0.77]); and increased school dropout rate (OR, 2.19 [95% CI, 1.73-2.78]) and school absenteeism (OR, 2.31 [95% CI, 1.76-3.03]). Absolute risk effects ranged from 7% to 14%. Low-certainty evidence suggested that cannabis use may be associated with increased unemployment (OR, 1.50 [95% CI, 1.15-1.96]), with an absolute risk increase of 9%. Subgroup analyses with moderate credibility showed worse academic outcomes for frequent cannabis users and for students who began cannabis use earlier.

Conclusions and Relevance

Cannabis use during adolescence and young adulthood was probably associated with increases in school absenteeism and dropout; reduced likelihood of obtaining high academic grades, graduating high school, enrolling in university, and postsecondary degree attainment; and perhaps increased unemployment. Further research is needed to identify interventions and policies that mitigate upstream and downstream factors associated with early cannabis exposure.

This systemic review and meta-analysis investigates whether cannabis use during adolescence and young adulthood is associated with academic performance.

Introduction

In 2019, 37% of US high school students reported lifetime cannabis use, and 22% endorsed use in the past month.¹ Furthermore, the potency of cannabis has increased over time in the US, from approximately 4% tetrahydrocannabinol in 1995 to 14% in 2019.^2,3 Adolescence and young adulthood are critical periods for brain development, and increasing acceptance and legalization of cannabis have raised concerns about implications for academic performance.⁴ Cannabis use can lead to short-term cognitive impairments, including memory deficits and impaired attention.⁵ Chronic use among adolescents has been linked to long-term changes in brain architecture, resulting in impaired information processing and decreased cognitive, memory, and attentive capacity in adulthood.^6,7

The most recent systematic review on adolescent cannabis use and academic achievement found that heavy cannabis use was associated with worse educational outcomes.⁸ However, this review had important limitations, including the lack of statistical pooling of associations, failure to assess the risk of bias of individual studies and overall certainty of evidence, and a limited search window (2014-2019). To address these limitations, we performed a systematic review and meta-analysis of the association of cannabis use during adolescence and young adulthood with academic achievement.

Methods

We followed the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline⁹ and guidance for systematic reviews and meta-analyses of prognostic studies.¹⁰ We registered our protocol on the Open Science Framework (https://doi.org/10.17605/OSF.IO/8Y2V7) and followed Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidance for communicating our findings.¹¹ Prior to analysis, we added 2 post hoc subgroup analyses: (1) legal availability of cannabis vs not, and (2) cross-sectional studies vs cohort studies. We also included a post hoc metaregression for year of enrollment (a proxy for potency of cannabis) and a post hoc sensitivity analysis by excluding studies from clinical settings.

Data Sources and Searches

We searched MEDLINE, EMBASE, PsycInfo, CINAHL, Scopus, and Web of Science from inception to November 10, 2023. Database-specific search strategies, without language restrictions, were developed by an academic librarian (eAppendix 1 in Supplement 1). We screened reference lists of all eligible studies and related reviews^8,12,13 for additional studies.

Study Selection

Paired reviewers screened the titles and abstracts of all citations and the full texts of potentially eligible studies independently and in duplicate. We included cohort or case-control studies that explored associations of cannabis use among adolescents and young adults (aged ≤24 years) with academic outcomes,¹⁴ regardless of mode of administration or purpose for use (recreational or medicinal). We excluded cross-sectional studies when cannabis use was assessed less than 1 year before academic outcomes, as the direction of association is therefore unclear. We also excluded studies that only reported associations with polysubstance use (use of cannabis and other drugs) without separate data for cannabis use. Small studies (sample size <20), conference abstracts, commentaries, and letters were excluded. When study populations overlapped by more than 50% between eligible articles, we included data from only the largest study for each outcome (eMethods in Supplement 1).

Data Extraction and Risk-of-Bias Assessment

After completing 4 calibration exercises, pairs of reviewers, working both independently and in duplicate, used a standardized and pilot-tested form to extract data. They assessed the risk of bias of each eligible study using criteria modified from the Users’ Guides to the Medical Literature¹⁵ (eMethods in Supplement 1).

Data Synthesis and Analysis

We used the DerSimonian-Laird random-effects model for all meta-analyses of academic outcomes reported by 3 or more studies, and we used fixed-effects models for meta-analyses of 2 studies.¹⁶ We pooled binary outcomes as odds ratios (ORs) and 95% CIs. We were unable to pool continuous outcomes as studies measured factors in the same domain using different scales. Instead, we compared the consistency between pooled and unpoolable results for the same types of outcomes.

Subgroup Analyses, Metaregression, and Sensitivity Analyses

We evaluated heterogeneity through visual inspection of forest plots and τ².¹⁷ To explore variability between studies, we tested the following a priori hypotheses, assuming worse outcomes with (1) cannabis legalization vs not, (2) recreational vs medicinal use, (3) frequent (weekly or daily) vs infrequent (less than weekly) use, (4) early (aged ≤16 years) vs later (aged >16 years) onset of cannabis use,¹³ (5) cannabis use modeled as trajectories vs reported directly, (6) studies at high vs low risk of bias, and (7) cross-sectional studies vs cohort studies. We conducted subgroup analyses only if each subgroup contained 2 or more studies. If there were at least 10 studies, we performed metaregression to explore the association between effects and proportion of loss to follow-up, length of follow-up, and year of enrollment. We assessed the credibility of significant subgroup effects using the Instrument for Assessing the Credibility of Effect Modification Analyses criteria.¹⁸

We conducted sensitivity analyses for each academic outcome comparing pooling of unadjusted vs adjusted data. If we found a significant difference, then we only used adjusted data for analysis. We also conducted a post hoc sensitivity analysis by excluding studies that recruited participants from clinical settings.

Certainty of Evidence

With GRADE, observational studies start as low-certainty evidence and may be further rated down for risk of bias, inconsistency, indirectness, imprecision, and small-study effects. Evidence may be rated up when pooled estimates show large effects (ie, OR ≥2 or ≤0.5), if they show a dose-response gradient, or if all plausible residual confounding would reduce the effect or increase the effect if none was observed.^17,19 We used visual assessment for asymmetry of funnel plots and calculation of the Begg test, whenever there were at least 10 studies contributing to meta-analysis, to assess small-study effects.^17,20 To facilitate the interpretation of the pooled estimates, we calculated the absolute risk decrease (ARD) or absolute risk increase (ARI) for each outcome amenable to meta-analysis by using the baseline risk for each academic outcome acquired from national US surveys conducted.^{21,22,23,24,25,26}

Data were analyzed from April 6 to May 25, 2024. All statistical analyses were performed using Stata version 18 (StataCorp LLC) statistical software. All comparisons were 2-tailed using a threshold P ≤ .05.

Results

Study Characteristics

We reviewed 17 622 citations, of which 62 English-language studies^{21,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87} and 1 Spanish-language study⁸⁸ proved eligible, including 53 primary studies with 55 unique cohorts^{27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,88} (n = 438 329) and 10 studies with 12 overlapping cohorts^{21,79,80,81,82,83,84,85,86,87} (n = 60 004) (Figure 1; eAppendices 2 and 3 in Supplement 1). Of the 63 studies, 2 studies^48,77 each included 3 cohorts with 2 of them overlapping.

Figure 1. — ^aTwo extra overlapping cohorts were identified and described by Silins et al.⁷⁷

To avoid double counting study populations, we analyzed baseline characteristics among the 53 primary studies without overlapping cohorts (eTable 1 in Supplement 1). Of the 55 cohorts in 53 studies, 65% were conducted in the US.^{27,28,29,30,31,32,33,35,36,37,40,41,42,43,44,46,47,49,50,51,52,54,56,58,59,60,61,62,65,66,68,69,70,71,73,74} Thirty-five studies (66%) were conducted in schools,^{27,28,29,30,31,32,33,35,36,37,38,39,40,42,43,46,47,49,50,51,52,54,56,57,58,62,63,64,65,69,71,74,75,76,88} 12 (23%) in communities,^{34,44,45,48,53,55,59,60,61,66,67,72} 4 in clinical settings,^41,68,73,78 and 2 in both school and community settings.^70,77 The median (IQR) of mean age among 31 studies was 16 (15-20) years, and the median (IQR) proportion of female participants among 47 studies was 52% (48%-58%). The median (IQR) proportion of White participants among 32 studies was 70% (52%-83%).

The pooled rate of cannabis use at baseline among 47 studies was 33% (95% CI, 25%-41%). Most studies (47 of 53 [89%]) did not report the purpose (recreational or medicinal), type, or route of cannabis use. Two studies^29,88 (4%) enrolled only recreational cannabis users, and 5 (9%) focused only on students who smoked cannabis.^{46,50,57,63,78}

Concurrent substance use was reported, including tobacco or cigarette use (median [IQR] proportion among 21 studies, 26% [22%-46%]), alcohol use (median [IQR] among 26 studies, 46% [28%-76%]), and cocaine or other substance use (median [IQR] among 15 studies, 10% [5%-21%]). Twelve studies reported substance use disorder, including cannabis abuse or dependence (median [IQR] proportion in 9 studies, 8% [7%-16%]), alcohol abuse or dependence (median [range] in 5 studies, 33% [28%-35%]), or substance use disorder (median [range] in 3 studies, 6% [3%-33%]).

Risk of Bias

Most studies (51 of 53 [96%]) were at high risk of bias for at least 1 criterion, including unrepresentative study populations in 16 studies (30%), failure to systematically approach participants for exposure and outcome information in 4 studies (8%), potential risk of recall bias regarding cannabis use in 43 studies (81%), uncertain validity of outcome measures in 33 studies (62%), and inadequate adjustment for confounding factors (ie, age, sex, and substance use or mental health disorders) in 32 studies (60%). Of the 44 studies that reported loss to follow-up, 30 (68%) were at high risk of bias (missing data ≥20%). Of the 33 studies that reported sources of funding, only 1 was partially industry funded⁵⁵ (eTable 2 in Supplement 1).

Sensitivity Analysis

No significant differences were found for adjusted vs unadjusted data regarding associations of cannabis use with higher school grades (eFigure 1A and eTable 3 in Supplement 1), dropout rate (eFigure 2A in Supplement 1), school absenteeism (eFigure 3A in Supplement 1), grade retention (eFigure 4A in Supplement 1), high school completion (eFigure 5A in Supplement 1), postsecondary degree attainment (eFigure 6A in Supplement 1), or unemployment (eFigure 7A in Supplement 1). We found a significant subgroup effect of moderate credibility that showed larger associations with unadjusted data vs adjusted data for university enrollment (eFigure 8A and eTable 3 in Supplement 1); therefore, we only used adjusted data for pooled analysis of this outcome (eTable 3 in Supplement 1). Sensitivity analysis showed consistent results across outcomes after excluding studies with clinical samples (eTable 4 in Supplement 1).

School Grades

Moderate-certainty evidence from 9 studies^{33,37,51,52,63,66,68,75,78} (n = 126 300) suggested that cannabis use was probably associated with decreased school grades (OR, 0.61 [95% CI, 0.52-0.71] for grade A or B; ARD, 8.4% [95% CI, 6.0%-10.6%]) (Figure 2 and Table). Two studies^52,75 (n = 28 390) reported significant within-study subgroup effects (moderate credibility) (eTables 5 and 6 in Supplement 1), indicating a larger association among more frequent cannabis users (weekly or daily; OR, 0.58 [95% CI, 0.53-0.64] vs less frequent cannabis users (less than weekly; OR, 0.72 [95% CI, 0.69-0.75]) (eFigure 1B, eTable 5, and eTable 6 in Supplement).

Figure 2. — Six studies reported both adjusted and unadjusted data, and only the adjusted data were used. NA indicates not applicable because adjusted data were used; OR, odds ratio.

Table. Grading of Recommendations Assessment, Development, and Evaluation Evidence Profile for Impact of Cannabis Use During Adolescence and Young Adulthood on Academic Outcomes.

.Outcome	No.		Quality assessment					Summary of findings			Reasons for rating up certainty of evidence	Overall certainty of evidence
.Outcome	Studies	Participants	Risk of bias	Inconsistency (τ²)	Indirectness	Imprecision	Small study effects	Adjusted OR (95% CI)	Baseline absolute risk, %	Absolute risk difference, % (95% CI)	Reasons for rating up certainty of evidence	Overall certainty of evidence
Academic grades A or B	9	185 917	No^a	No (0.04)	No	No	NA; only 9 studies	0.61 (0.52-0.71)	26	−8.4 (−6.0 to −10.6)	Dose-response gradient	Moderate^b
School dropout^c	9	27 301	No^a	No (0.08)	No	No	NA; only 9 studies	2.19 (1.73-2.78)	10	9.6 (6.1 to 13.6)	Large association	Moderate^d
School absenteeism	9	120 448	Yes^e	No (0.14)^f	No	No	NA; only 9 studies	2.31 (1.76-3.03)	15	14 (8.7 to 19.8)	Large association and dose-response gradient	Moderate^b^,^d
Grade retention	3	22 475	Yes	No (0.08)	No	Yes^g	NA; only 3 studies	1.41 (0.97-2.03)	24	6.8 (−0.6 to 15.1)	NA	Very low
High school completion	6	10 251	No^a	Yes (0.21)	No	No	NA; only 6 studies	0.50 (0.33-0.76)	90	−8.2 (−2.8 to −15.2)	Large association and dose-response gradient	Moderate^b^,^d
University enrollment	6	22 693	No^a	No (0.04)^f	No	No	NA; only 6 studies	0.72 (0.60-0.87)	43	−7.8 (−3.4 to −11.8)	Dose-response gradient	Moderate^b
Postsecondary degree attainment	8	18 379	No^a	No (0.008)	No	No	NA; only 8 studies	0.69 (0.62-0.77)	80	−6.6 (−4.5 to −8.7)	Dose-response gradient	Moderate^b
Unemployment	6	5537	Yes^e	No (0.06)^f	No	No	NA; only 6 studies	1.50 (1.15-1.96)	26	8.5 (2.8 to 14.8)	Dose-response gradient	Low^b

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Abbreviations: NA, not applicable; OR, odds ratio.

^{^a}

Not rated down for risk of bias due to nonsignificant subgroup effects between studies with high vs low risk of bias.

^{^b}

Rated up 1 level for the certainty of evidence due to the dose-response gradient.

^{^c}

Due to significant subgroup effect for high vs low risk of bias in validity of outcome measure (P < .001, moderate credibility), the association was reported among studies with low risk of bias.

^{^d}

Rated up 1 level for the certainty of evidence due to the large magnitude of association (OR > 2 or OR < 0.5).

^{^e}

High risk of bias of invalid cannabis measure.

^{^f}

Although the wider prediction interval included the null effect, which was driven mainly by 1 outlier, this was not rated down for inconsistency because τ² was relatively small, the point estimates were in the same direction, and a similar overall effect estimate was found with well-overlapped 95% CIs and reduced τ² after excluding 1 outlier.

^{^g}

Rated down for imprecision because of the 95% CI crossing the null effect line (nonsignificant association).

School Dropout

We found a significant subgroup effect between studies at high vs low risk of bias for validity of outcome measure (moderate credibility) (eFigure 2B, eTable 5, and eTable 6 in Supplement 1). Moderate-certainty evidence from 9 studies^{21,28,31,34,54,78,84,85,86} at low risk of bias (n = 27 301) showed cannabis use was probably associated with increased odds of dropping out of school (OR, 2.19 [95% CI, 1.73-2.78]; ARI, 9.6% [95% CI, 6.1%-13.6%]) (Figure 3 and Table).

Figure 3. — Eight studies reported both adjusted and unadjusted data, and only the adjusted data were used. Due to a significant subgroup effect for high vs low risk of bias in the validity of the outcome measure (P < .001, moderate credibility), the primary analysis of school dropout was performed among the studies with low risk of bias. NA indicates not applicable because adjusted data were used; OR, odds ratio.

School Absenteeism

Moderate-certainty evidence from 9 studies^{35,51,57,58,59,66,68,75,88} (n = 120 448) found that cannabis use was probably associated with school absenteeism (OR, 2.31 [95% CI, 1.76-3.03]; ARI, 14% [95% CI, 8.7%-19.8%]) (eFigure 3B in Supplement 1; Table). Significant within-study subgroup effects (moderate credibility) (eTables 5 and 6 in Supplement 1) from 2 studies^59,75 (n = 41 643) showed a larger association among more frequent cannabis users (OR, 6.20 [95% CI, 5.51-6.98]) vs less frequent cannabis users (OR, 3.10 [95% CI, 2.96-3.25]) (eFigure 3C, eTable 5, and eTable 6 in Supplement 1).

Grade Retention

We found only very low-certainty evidence from 3 studies^39,80,88 (n = 22 475). We are therefore uncertain about the impact of cannabis use on grade retention (OR, 1.41 [95% CI, 0.97-2.03]) (eFigure 4B in Supplement 1; Table).

High School Completion

Moderate-certainty evidence from 6 studies^{48,72,76,77,84,87} (n = 10 251) found that cannabis use was probably associated with decreased odds of completing high school (OR, 0.50 [95% CI, 0.33-0.76]; ARD, 8.2% [95% CI, 2.8%-15.2%]) (eFigure 5B in Supplement 1; Table). Significant within-study subgroup effects (moderate credibility) (eTables 5 and 6 in Supplement 1) from 2 studies^48,76 (n = 4446) showed a larger association among cannabis users with early onset (starting at age ≤16 years; OR, 0.42 [95% CI, 0.28-0.63]) than among those with later onset (starting at >16 years; OR, 0.77 [95% CI, 0.53-1.10]) (eFigure 5C, eTable 5, and eTable 6 in Supplement 1).

University Enrollment

Moderate-certainty evidence from 6 studies^{38,48,72,77,78,86} with adjusted data (n = 22 693) found cannabis use was probably associated with decreased university enrollment (OR, 0.72 [95% CI, 0.60-0.87]; ARD, 7.8% [95% CI, 3.4%-11.8%]) (Figure 4 and Table). Significant within-study subgroup effects (moderate credibility) (eTables 5 and 7 in Supplement 1) from 4 studies^38,72,77,78 (n = 8976) showed a larger association among more frequent cannabis users (OR, 0.57 [95% CI, 0.45-0.71]) vs less frequent cannabis users (OR, 0.81 [95% CI, 0.70-0.93]) (eFigure 8B, eTable 5, and eTable 7 in Supplement 1).

Figure 4. — Five studies reported both adjusted and unadjusted data, and 1 study reported adjusted data only. Adjusted data were used from all of the 6 studies due to the significant difference between studies with adjusted and unadjusted data (P = .01, moderate credibility). OR indicates odds ratio.

Educational Attainment

Moderate-certainty evidence from 8 studies^{41,44,48,55,76,77,81,83} with adjusted data (n = 18 379) showed that cannabis use was probably associated with postsecondary degree attainment (OR, 0.69 [95% CI, 0.62-0.77]; ARD, 6.6% [95% CI, 4.5%-8.7%]) (eFigure 6B in Supplement 1; Table). Significant within-study subgroup effects (moderate credibility) (eTables 5 and 7 in Supplement 1) from 2 studies^77,83 (n = 4418) showed a larger association among more frequent cannabis users (OR, 0.47 [95% CI, 0.33-0.66]) vs less frequent cannabis users (OR, 0.69 [95% CI, 0.61-0.78]) (eFigure 6C, eTable 5, and eTable 7 in Supplement 1).

Unemployment

Low-certainty evidence from 6 studies^{28,33,35,45,76,83} (n = 5537) suggested that cannabis use might be associated with increased odds of unemployment (OR, 1.50 [95% CI, 1.15-1.96]; ARI, 8.5% [95% CI 2.8%-14.8%]) (eFigure 7B in Supplement 1; Table). Two studies^45,83 (n = 2430) reported significant within-study subgroup effects (moderate credibility) (eTables 5 and 7 in Supplement 1), indicating a larger association among more frequent cannabis users (OR, 1.93 [95% CI, 1.34-2.77]) vs less frequent cannabis users (OR, 1.20 [95% CI, 1.09-1.32]) (eFigure 7C, eTable 5, and eTable 7 in Supplement 1).

Subgroup Analysis and Metaregression

We were unable to perform subgroup analysis for recreational vs medicinal use of cannabis and metaregression for length of follow-up due to inadequate information. Aside from those noted earlier, no additional subgroup effects or metaregressions proved credible (eTables 5-8 and eFigures 1B-8C in Supplement 1).

Nonpoolable Studies

Twenty-seven studies^{27,29,30,32,35,36,40,42,43,47,49,50,56,58,59,60,61,62,64,65,69,70,71,74,78,82,84} reported outcomes that were not amenable to pooling. However, their results were consistent with pooled studies (eTables 9-11 in Supplement 1).

Discussion

In this systematic review and meta-analysis of 63 observational studies^{21,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88} involving more than 400 000 adolescents and young adults, moderate-certainty evidence showed cannabis use was probably associated with reduced school grades, high school completion, university enrollment, and postsecondary degree attainment and increased school absenteeism and dropout. Low-certainty evidence suggested that cannabis use in adolescence and young adulthood may be associated with increased unemployment. Available evidence for cannabis use and grade retention proved to be of very low certainty.

We found that frequent cannabis use (daily or weekly), compared with less frequent use, was associated with lower school grades, higher school absenteeism, less likelihood of university enrollment and postsecondary degree attainment, and greater odds of unemployment. We observed a larger association with lower high school completion rate in cannabis users with early onset (starting at age ≤16 years) vs later onset (aged >16 years).

The most recent systematic review exploring cannabis use and academic outcomes identified 12 studies, of which 11 reported significant associations of heavy and/or chronic adolescent cannabis use with lower academic achievement.⁸ Our review, which identified 45 additional studies without overlapping cohorts,^{27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,88} confirmed these findings, explored a wider range of academic outcomes, conducted meta-analyses to quantify associations, and assessed the certainty of evidence. Further, we found that frequent and early-onset cannabis use was associated with worse academic outcomes.

Although our findings support a negative association between cannabis use and academic achievement, the mechanism of action is uncertain. Cannabis-induced impairment of cognitive function and motivation may play a role; however, whether cannabis use is a cause, correlate, or consequence of these factors is inconclusive.⁸⁹ Other studies suggested that poor mental health status⁹⁰ or having affiliations with drug-using or delinquent peers¹³ may predispose youths to cannabis use and poor academic achievement. However, our review only included studies where cannabis use was measured before academic outcomes, and our findings were robust to sensitivity analysis that adjusted for other substance use or mental disorders.

Previous systematic reviews and meta-analyses reported that cannabis use in adolescence and young adulthood is associated with increased risk of psychosis,⁹¹ depression, and suicidality.⁹² One in 6 adolescent cannabis users meets diagnostic criteria for dependence.⁹³ Worldwide, cannabis use disorder accounts for 11 900 disability-adjusted life-years among individuals aged 10 to 14 years, peaking at ages 20 to 24 years (163 000 disability-adjusted life-years).⁹⁴ With a growing number of countries and most US states legalizing medical and/or recreational cannabis, there is a trend of increased cannabis consumption coincident to decreased risk perceptions of its harms. This raises critical concerns about its potential negative impact, particularly on youths. US national estimates indicate that more than 3 million youths aged 12 to 17 years have used cannabis in the past year, which is greater use than any other illicit drug.⁹⁵

Screening youths at elevated risk of initiating cannabis use could facilitate prevention and early intervention strategies. Systematic reviews have explored the effectiveness of universal multimodal prevention programs (which address familial, peer, community, and school-based factors),⁹⁶ universal multiple risk behavior interventions,⁹⁷ and school-based programs (collaborating with health professionals, police officers, or program specialists)⁹⁸ to reduce cannabis use among youths; however, the certainty of evidence for these interventions is low and effectiveness inconclusive. Further research to establish effective prevention programs is warranted.

Strengths and Limitations

Strengths of our review include (1) a comprehensive search that identified 55 studies^{21,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,79,80,81,82,83,84,85,86,87,88} (including 45 primary studies^{27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,88}) that were not included in the previous systematic review, (2) use of GRADE to evaluate the certainty of evidence, (3) conversion of pooled measures of association to absolute risks to optimize interpretability, and (4) subgroup and sensitivity analyses to explore variability between studies.

There are several limitations to our review. We were unable to pool some data from studies that used different measures for common outcome domains; however, the results from these studies were consistent with our pooled estimates. Most studies eligible for our review were at high risk of bias. High variability existed across studies in measures of cannabis use, study populations, geographic areas where studies were conducted, and cannabis-related policies; however, adjusted analysis showed consistent associations. Furthermore, a 2024 systematic review⁹⁹ found that legalization of cannabis for medical purposes was not associated with past-month use among youths (OR, 0.98 [95% CI, 0.96-1.00]), whereas legalization of recreational cannabis was (OR, 1.22 [95% CI, 1.19-1.26]). Due to scarcity of data, we were unable to explore the impact of legal status or recreational vs medicinal cannabis use as possible sources of variability for most outcomes. Moreover, we were unable to run subgroup analyses for types and potency of cannabis due to insufficient data, and some of our analyses may have been underpowered to identify subgroup effects; therefore, the impact of cannabis type and the change in its potency are not elucidated for all outcomes. Additionally, most studies eligible for our review were conducted in the US, and the generalizability of our findings to middle- and low-income countries is uncertain. Also, our findings are based on observational studies, which do not allow for causal inferences; however, the large associations and dose-response gradients we found for several outcomes increase our confidence in our findings.

Conclusions

This systematic review and meta-analysis found moderate-certainty evidence that cannabis use during adolescence and young adulthood is probably associated with increased school absenteeism and dropout and reduced likelihood of obtaining high academic grades, graduating high school, enrolling in university, or postsecondary degree attainment. Low-certainty evidence suggests that cannabis use during adolescence and young adulthood may be associated with increased unemployment. More frequent cannabis use and earlier onset were associated with worse academic outcomes. Effective interventions to prevent early cannabis exposure are urgently needed.

Supplement 1.

eMethods. Supplemental Methods

eTable 1. Baseline Characteristics of 53 Primary Studies

eTable 2. Risk of Bias Assessment of 53 Primary Studies

eTable 3. Sensitivity Analyses Summary Table for Unadjusted vs Adjusted Data

eTable 4. Sensitivity Analyses Summary Table After Excluding Studies at Clinical Settings

eTable 5. Subgroup Analyses Summary Table

eTable 6. ICEMAN Criteria for Assessing the Credibility of Subgroup Effects of GPA, School Dropout, School Absenteeism, and High School Completion

eTable 7. ICEMAN Criteria for Assessing the Credibility of Subgroup Effects of Education Attainment, University Enrollment and Unemployment

eTable 8. Metaregression for Proportion of Loss to Follow-Up and Year of Enrollment

eTable 9. Consistency of Results of Eight Outcomes Between Pooled and Unpooled Studies

eTable 10. Consistency of Results of Dose-Response (Frequent vs Infrequent Cannabis Use) Between Pooled and Unpooled Studies

eTable 11. Consistency of Results of Early Cannabis Use vs Late Cannabis Use Between Pooled and Unpooled Studies

eFigure 1. School Grades

eFigure 2. School Dropout

eFigure 3. School Absenteeism

eFigure 4. Grade Retention

eFigure 5. High School Completion

eFigure 6. Educational Attainment (Post-Secondary Degree Attainment)

eFigure 7. Unemployment

eFigure 8. University Enrollment

eAppendix 1. Literature Search Strategies

eAppendix 2. Reference List of Included Studies

eAppendix 3. Reference List of Excluded Studies

jamapediatr-e243674-s001.pdf^{(4.5MB, pdf)}

Supplement 2.

Data Sharing Statement

jamapediatr-e243674-s002.pdf^{(17.2KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eMethods. Supplemental Methods

eTable 1. Baseline Characteristics of 53 Primary Studies

eTable 2. Risk of Bias Assessment of 53 Primary Studies

eTable 3. Sensitivity Analyses Summary Table for Unadjusted vs Adjusted Data

eTable 4. Sensitivity Analyses Summary Table After Excluding Studies at Clinical Settings

eTable 5. Subgroup Analyses Summary Table

eTable 6. ICEMAN Criteria for Assessing the Credibility of Subgroup Effects of GPA, School Dropout, School Absenteeism, and High School Completion

eTable 7. ICEMAN Criteria for Assessing the Credibility of Subgroup Effects of Education Attainment, University Enrollment and Unemployment

eTable 8. Metaregression for Proportion of Loss to Follow-Up and Year of Enrollment

eTable 9. Consistency of Results of Eight Outcomes Between Pooled and Unpooled Studies

eTable 10. Consistency of Results of Dose-Response (Frequent vs Infrequent Cannabis Use) Between Pooled and Unpooled Studies

eTable 11. Consistency of Results of Early Cannabis Use vs Late Cannabis Use Between Pooled and Unpooled Studies

eFigure 1. School Grades

eFigure 2. School Dropout

eFigure 3. School Absenteeism

eFigure 4. Grade Retention

eFigure 5. High School Completion

eFigure 6. Educational Attainment (Post-Secondary Degree Attainment)

eFigure 7. Unemployment

eFigure 8. University Enrollment

eAppendix 1. Literature Search Strategies

eAppendix 2. Reference List of Included Studies

eAppendix 3. Reference List of Excluded Studies

jamapediatr-e243674-s001.pdf^{(4.5MB, pdf)}

Supplement 2.

Data Sharing Statement

jamapediatr-e243674-s002.pdf^{(17.2KB, pdf)}

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PERMALINK

Cannabis Use During Adolescence and Young Adulthood and Academic Achievement

Olsen Chan, BHSc

Ahad Daudi, BHSc

David Ji

Mathias Wang, BHSc

Jeremy P Steen, BHSc

Parsia Parnian

Crystal Li

Annie Xiong

Wei Zhang, MA, MLIS

Luciane C Lopes, ScD, MSc

James MacKillop, PhD

Jason W Busse, DC, PhD

Li Wang, PhD

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Data Sources

Study Selection

Data Extraction and Synthesis

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Data Sources and Searches

Study Selection

Data Extraction and Risk-of-Bias Assessment

Data Synthesis and Analysis

Subgroup Analyses, Metaregression, and Sensitivity Analyses

Certainty of Evidence

Results

Study Characteristics

Figure 1. Flow Diagram for Study Selection.

Risk of Bias

Sensitivity Analysis

School Grades

Figure 2. Achievement of a School Grade of A or B.

Table. Grading of Recommendations Assessment, Development, and Evaluation Evidence Profile for Impact of Cannabis Use During Adolescence and Young Adulthood on Academic Outcomes.

School Dropout

Figure 3. Forest Plot for School Dropout.

School Absenteeism

Grade Retention

High School Completion

University Enrollment

Figure 4. Forest Plot for University Enrollment.

Educational Attainment

Unemployment

Subgroup Analysis and Metaregression

Nonpoolable Studies

Discussion

Strengths and Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Links to NCBI Databases