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. 2026 Sep 24;9(9):e2635815. doi: 10.1001/jamanetworkopen.2026.35815

Simultaneous Cannabis and Alcohol Use From Nationally Representative Data

Beth Han 1, Jennifer A Hobin 1, Wilson M Compton 1,✉
PMCID: PMC13613188  PMID: 42783374

Abstract

This cross-sectional study compares past-month simultaneous use of cannabis and alcohol with alcohol-only and cannabis-only use among adults in the US.

Introduction

Alcohol and cannabis are commonly used substances, with cannabis use increasing alongside expanding cannabis legalization.1 Although simultaneous alcohol-cannabis use has been associated with adverse outcomes,2 studies have compared simultaneous alcohol-cannabis use with alcohol-only use3,4 or with heterogeneous groups using alcohol only, cannabis only, and neither.5,6 To clarify alcohol-cannabis use patterns, identify risk factors, and strengthen clinical and public health responses in a rapidly evolving substance-use landscape, we compared adults who use cannabis and alcohol simultaneously with adults who use them separately.

Methods

This cross-sectional study examined data from participants aged 18 years or older who completed the 2021-2024 National Surveys on Drug Use and Health (NSDUH). The NSDUH data collection protocols were approved by the RTI International Institutional Review Board, and participants provided informed consent.7 This study used publicly available, deidentified data and was considered exempt from review per National Institutes of Health Institutional Review Board policy. This study followed the STROBE reporting guideline for cross-sectional studies.

The NSDUH provides nationally representative data on simultaneous alcohol-cannabis use based on questions about using cannabis while drinking or within a couple of hours of drinking during the last drinking episode in the past month among civilian, noninstitutionalized adults living in the US.7 Separate use of alcohol and cannabis was defined as past-month alcohol and cannabis use without simultaneous alcohol-cannabis use. The NSDUH collected sociodemographic characteristics (age, sex, self-reported race and ethnicity by US Census Bureau classifications [American Indian or Alaska Native, Asian, Black, Hispanic, Native Hawaiian or Pacific Islander, White, multiracial]); past-year major depressive episode (MDE), alcohol use disorder, cannabis use disorder (CUD), and other drug use disorders (all using Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition] criteria); past-year suicidal ideation; and past-month serious psychological distress and nicotine dependence.

Descriptive and bivariate and multivariable logistic regression analyses were performed were conducted using SUDAAN, release 11.0.1 (RTI International) to account for NSDUH’s complex sample design and sampling weights. Adjusted prevalence was estimated from model-predicted marginal probabilities. A 2-tailed P < .05 was considered significant. After identifying interaction effects between age and sex (P < .001) and between age and MDE (P = .02), we stratified analyses by age.

Results

Data were from 186 823 adults (51.3% female and 48.7% male; 53.8% aged 18-49 years). The mean weighted household screening response rate was 23.5%; the adult interview response rate was 49.5%. Among adults in the US, 51.6% (95% CI, 51.1%-52.1%) used alcohol, 15.7% (95% CI, 15.4%-16.0%) used cannabis, and 11.2% (95% CI, 10.9%-11.5%) used both substances in the past month. Of those using both (Figure), 49.0% (95% CI, 47.8%-50.2%; 14.1 million [95% CI, 13.6-14.7 million] after weighting) reported simultaneous alcohol-cannabis use, which was common across examined factors, with highest prevalence among those aged 50 years or older with CUD (82.0% [95% CI, 75.9%-86.8%]) (Table).

Figure. Bar Graph of Past-Month Use of Alcohol and Cannabis Among US Adults.

Bar chart of adults with past-month substance use, in millions, across four categories. Single-panel vertical bar chart with four teal-blue bars and small black error bars at each bar top. Horizontal axis has four category labels, each split across lines: Past-month alcohol use; Past-month cannabis use; Past-month alcohol and cannabis use; Used cannabis during the last drinking episode. Vertical axis label at left reads No. of adults with past-month substance use, millions. Vertical axis tick labels run from 0 at the bottom to 140 at the top in increments of 20, with light gray horizontal gridlines at each tick. The first bar, aligned above Past-month alcohol use, reaches a little above 130, approximately 133 million, with a short error bar extending slightly above and below the bar top. The second bar, above Past-month cannabis use, reaches about 40 million, with a very small error bar. The third bar, above Past-month alcohol and cannabis use, reaches just under 30 million, approximately 29 million, with a very small error bar. The fourth bar, above Used cannabis during the last drinking episode, reaches a little under 15 million, approximately 14 million, with a very small error bar. No legend, panel labels, or data point markers appear.

Error bars indicate standard errors. Data source: 2021-2024 National Surveys on Drug Use and Health.

Table. Adjusted Prevalence and Prevalence Ratios of Cannabis Use During the Last Drinking Episode Among Adults Reporting Past-Month Use of Both Alcohol and Cannabis, Stratified by Age (N = 23 897)a.

Factor Age group
Adjusted prevalence of simultaneous alcohol-cannabis use, % (95% CI) APR of simultaneous alcohol-cannabis use vs separate use (95% CI)
18-29 y (n = 12 258) 30-49 y (n = 9178) ≥50 y (n = 2461) 18-29 y (n = 12 258) 30-49 y (n = 9178) ≥50 y (n = 2461)
Young adult age group, y
18-20 46.1 (42.4-49.8)b NA NA 0.75 (0.72-0.87)b NA NA
21-23 52.8 (50.4-55.2)b NA NA 0.90 (0.85-0.95)b NA NA
24-25 54.1 (51.1-57.0)b NA NA 0.92 (0.86-0.98)b NA NA
26-29c 58.7 (56.0-61.4) NA NA 1 [Reference] NA NA
Adult age group, y
30-34 NA 51.2 (49.0-53.5) NA NA 1.00 (0.94-1.07) NA
35-49c NA 51.0 (48.6-53.4) NA NA 1 [Reference] NA
Older adult age group, y
50-64 NA NA 46.5 (42.4-50.6) NA NA 1.03 (0.90-1.18)
≥65c NA NA 45.1 (40.1-50.2) NA NA 1 [Reference]
Sex
Femalec 53.0 (50.8-55.2) 49.5 (47.2-51.8) 39.0 (34.9-43.2) 1 [Reference] 1 [Reference] 1 [Reference]
Male 55.2 (53.0-57.4) 52.3 (50.2-54.4)b 51.4 (47.7-55.1)b 1.04 (0.99-1.10) 1.06 (1.01-1.11)b 1.32 (1.20-1.45)b
Race and ethnicityd
American Indian or Alaska Native 60.1 (49.3-70.0) 46.7 (34.0-60.0) 51.7 (25.9-76.6) 1.10 (0.93-1.31) 0.90 (0.68-1.20) 1.10 (0.63-1.91)
Asian or Native Hawaiian or Pacific Islander 54.9 (45.9-63.7) 46.0 (35.3-57.1) 33.4 (15.4-57.9) 1.01 (0.84-1.20) 0.89 (0.70-1.13) 0.71 (0.36-1.39)
Black 56.5 (52.6-60.4) 54.6 (50.3-58.8) 47.1 (37.7-56.7) 1.03 (0.96-1.12) 1.05 (0.97-1.15) 1.00 (0.83-1.22)
Hispanic 50.2 (46.1-54.3)b 45.3 (40.5-50.2)b 39.5 (27.7-52.6) 0.92 (0.86-0.99)b 0.87 (0.78-0.98)b 0.84 (0.60-1.18)
Whitec 54.6 (52.6-56.7) 51.8 (49.9-53.7) 47.0 (43.4-50.6) 1 [Reference] 1 [Reference] 1 [Reference]
Multiracial 56.8 (50.8-62.7) 53.0 (45.4-60.8) 41.5 (28.5-55.9) 1.04 (0.92-1.17) 1.02 (0.88-1.19) 0.88 (0.63-1.24)
Educational attainment
Less than high school 58.1 (53.5-62.6)b 52.3 (46.9-57.7)b 50.0 (38.4-61.7) 1.21 (1.09-1.35)b 1.15 (1.02-1.29)b 1.22 (0.92-1.61)
High school graduate 58.1 (54.8-61.2)b 57.3 (53.3-61.2)b 50.6 (43.6-57.6)b 1.21 (1.12-1.32)b 1.26 (1.10-1.38)b 1.23 (1.04-1.46)b
Some college 55.1 (52.6-57.5)b 53.6 (50.7-56.4)b 46.6 (42.1-51.2) 1.15 (1.07-1.24)b 1.17 (1.08-1.27)b 1.13 (0.98-1.30)
College graduatec 47.9 (44.8-51.0) 45.6 (42.5-48.7) 41.1 (36.5-46.0) 1 [Reference] 1 [Reference] 1 [Reference]
Self-rated health
Excellent 52.5 (48.3-56.6) 50.5 (45.7-55.2) 45.0 (38.1-52.0) 0.98 (0.87-1.10) 1.03 (0.91-1.17) 1.20 (0.96-1.51)
Very good 53.2 (51.2-55.2) 51.5 (48.8-54.1) 47.7 (42.3-53.2)b 0.99 (0.90-1.08) 1.05 (0.95-1.18) 1.28 (1.03-1.59)b
Good 56.2 (53.6-58.9) 51.7 (48.3-55.1) 49.3 (44.4-54.2)b 1.04 (0.95-1.15) 1.06 (0.93-1.21) 1.32 (1.09-1.60)b
Fair or poorc 53.8 (49.2-58.4) 48.9 (44.2-53.7) 37.4 (30.7-44.5) 1 [Reference] 1 [Reference] 1 [Reference]
MDE
Yes 56.0 (53.2-58.7) 57.4 (53.5-61.2)b 64.6 (54.5-73.6)b 1.04 (0.99-1.11) 1.14 (1.07-1.23)b 1.45 (1.23-1.70)b
Noc 53.6 (51.6-55.5) 50.1 (48.3-51.9) 44.6 (41.3-48.1) 1 [Reference] 1 [Reference] 1 [Reference]
Alcohol use disorder
Yes 54.6 (51.8-57.4) 54.3 (51.5-57.2)b 48.3 (42.9-53.8) 1.01 (0.96-1.07) 1.10 (1.03-1.17)b 1.07 (0.93-1.23)
Noc 53.9 (52.2-55.6) 49.6 (47.4-51.7) 45.2 (41.2-49.2) 1 [Reference] 1 [Reference] 1 [Reference]
CUD
Yes 72.2 (70.4-74.0)b 77.4 (74.4-80.2)b 82.0 (75.9-86.8)b 2.14 (2.01-2.29)b 2.09 (1.95-2.24)b 2.09 (1.85-2.35)b
Noc 33.7 (31.6-35.9) 37.1 (35.0-39.2) 39.3 (35.5-43.1) 1 [Reference] 1 [Reference] 1 [Reference]
Other drug use disorder
Yes 53.9 (48.1-59.6) 41.7 (36.6-47.0)b 40.3 (30.0-51.4) 0.99 (0.88-1.12) 0.80 (0.71-0.91)b 0.87 (0.67-1.13)
Noc 54.2 (52.3-56.1) 51.9 (50.1-53.8) 46.3 (43.0-49.7) 1 [Reference] 1 [Reference] 1 [Reference]

Abbreviations: APR, adjusted prevalence ratio; CUD, cannabis use disorder; MDE, major depressive episode; NA, not applicable; NSDUH, National Survey on Drug Use and Health.

a

Data source: 2021-2024 NSDUH.

b

Statistically significantly different from the corresponding estimate of the reference group at P < .05.

c

Reference group. Survey year, income, employment, marital status, metropolitan statistical area status, suicidal ideation, serious psychological distress, and nicotine dependence did not distinguish the 2 groups, which were excluded from the final parsimonious model for a descriptive association approach.

d

The NSDUH respondents self-identified racial and ethnic origin according to the classifications developed by the US Census Bureau.

A number of demographic and behavioral health factors were associated with simultaneous use. For instance, among adults aged 18 to 29 years with past-month cannabis and alcohol use, simultaneous alcohol-cannabis use was more prevalent among high school graduates (adjusted prevalence ratio [APR], 1.21 [95% CI, 1.12-1.32]) and those with CUD (APR, 2.14 [95% CI, 2.01-2.29]) (Table). Among adults aged 30 to 49 years using both substances, simultaneous use was more prevalent among males (APR, 1.06 [95% CI, 1.01-1.11]), high school graduates (APR, 1.26 [95% CI, 1.10-1.38]), and those with MDE (APR, 1.14 [95% CI, 1.07-1.23]) and CUD (APR, 2.09 [95% CI, 1.95-2.24]). Among adults aged 50 years or older using both substances, simultaneous use was more prevalent among males (APR, 1.32 [95% CI, 1.20-1.45]); high school graduates (APR, 1.23 [95% CI, 1.04-1.40]); and those reporting good health (APR, 1.32 [95% CI, 1.09-1.60]), with MDE (APR, 1.45 [95% CI, 1.23-1.70]), and with CUD (APR, 2.09; 95% CI, 1.85-2.35).

Discussion

This cross-sectional study found that among adults in the US with past-month alcohol and cannabis use, 49.0% (14.1 million weighted) reported simultaneous alcohol-cannabis use during their last drinking episode. Prevalence was highest among individuals with CUD. Simultaneous alcohol-cannabis use may be a routine pattern for adults (especially older adults) with CUD, suggesting normalization of simultaneous use despite potential compounded risks, including impaired judgment, injury, and intoxication effects.2 Cannabis use disorder is associated with adverse physical, cognitive, and psychosocial outcomes,8 with prevalence and severity increasing.9 To reduce related harms, future research should examine how simultaneous alcohol-cannabis use trends relate to cannabis accessibility, social acceptance, legalization, and perceived benefits.

Age-specific screening and intervention are needed to address simultaneous alcohol-cannabis use. Older adults with CUD who drink may warrant increased clinical attention given high simultaneous use prevalence and age-related elevated risks. Simultaneous use was elevated in older men and individuals with MDE, but no sex or MDE association was observed among young adults, suggesting age-specific mechanisms and motives.

The study may have underestimated simultaneous alcohol-cannabis use prevalence because NSDUH excluded populations experiencing unsheltered homelessness and incarceration10 and did not survey cannabis use during any past-month drinking episodes. Despite these limitations, findings show that simultaneous alcohol-cannabis use is common—especially among those with CUD who drink. Findings may inform future research, highlighting the need for awareness of simultaneous use harms, age-specific screening, interventions, risk-focused counseling, and timely referrals. Impaired-driving education may benefit from addressing alcohol- and cannabis-related impairment.

Supplement.

Data Sharing Statement

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Supplementary Materials

Supplement.

Data Sharing Statement


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