European Neuropsychopharmacology (2020) 36, 169–180

www.elsevier.com/locate/euroneuro

Adolescent cannabis use, cognition, brain

health and educational outcomes: A review
of the evidence
Valentina Lorenzetti a, Eva Hoch b, Wayne Hall c,∗

a
School of Behavioural and Health Sciences, Faculty of Health Sciences, Australian Catholic University,
Melbourne, Victoria, Australia
b
Cannabinoid Research and Treatment Group, Department of Psychiatry and Psychotherapy, University
Hospital, and Division of Clinical Psychology and Psychological Treatment, Department of Psychology,
Ludwig Maximilian University, Munich, Germany
c
Centre for Youth Substance Abuse Research, The University of Queensland, St Lucia, Queensland,
Australia

Received 3 October 2019; received in revised form 10 February 2020; accepted 13 March 2020

KEYWORDS Abstract
Cannabis; We review the findings of systematic reviews and meta-analyses of case-control studies that
Cognitive effects; examine brain functioning and cognitive correlates of adolescent cannabis use using structural
Adolescence and functional neuroimaging tools and standardised neuropsychological tests. We also exam-
ine prospective epidemiological studies on the possible effects of adolescent and young adult
cannabis use on cognitive performance in adult life and the completion of secondary education.
We summarize the findings of studies in each of these areas that have been published since the
most recent systematic review. Systematic reviews find that adolescent cannabis use is incon-
sistently associated with alterations in the structure of prefrontal and temporal brain regions.
Meta-analyses reveal functional alterations in the parietal cortex and putamen. Differences in
the orbitofrontal cortex predate cannabis use; it is unclear if they are affected by continued
cannabis use and prolonged abstinence. Longitudinal and twin studies report larger declines in
IQ among cannabis users than their non-using peers but it is unclear whether these findings can
be attributed to cannabis use or to genetic, mental health and environmental factors. Several
longitudinal studies and a meta-analysis of cross-sectional studies suggest that there is some
cognitive recovery after abstinence from cannabis. Longitudinal studies and some twin studies

∗ Corresponding
author at: 17 Upland Road, St Lucia QLD 4072 Australia and the National Addiction center, Kings College London, United
Kingdom.
E-mail address: w.hall@uq.edu.au (W. Hall).

https://doi.org/10.1016/j.euroneuro.2020.03.012
0924-977X/© 2020 Elsevier B.V. and ECNP. All rights reserved.
170 V. Lorenzetti, E. Hoch and W. Hall

have found that cannabis users are less likely to complete secondary school than their non-using
controls. This association might reflect an effect of cannabis use and/or the social environment
of cannabis users and their cannabis using peers. Cognitive performance is altered in some do-
mains (e.g. IQ, verbal learning) in young people while they are regularly using cannabis.
There are two important messages to adolescents and young adults: First, cannabis has po-
tentially detrimental effects on cognition, brain and educational outcomes that persist beyond
acute intoxication. Second, impaired cognitive function in cannabis users appears to improve
with sustained abstinence.
© 2020 Elsevier B.V. and ECNP. All rights reserved.

1. Introduction potency (Hall et al., 2019). Legalization does appear to

We assess the available evidence on whether cannabis use
adversely affects learning, attention, and decision-making
in youth, a group whom we define as between the ages of
14 and 25 years (Mills et al., 2016). We do so because we
believe this topic ought to be central to debates about how
cannabis is regulated and what young people are told about
the risks of cannabis use under cannabis legalization, a pol-
icy that is being adopted by an increasing number of coun-
tries.
Cannabis is the illicit drug most often used in adoles-
cence (Hasin et al., 2013). In 2017 it was used by ap-
proximately 12.6 million students aged 15–16 worldwide
(UNODC, 2019b) and an estimated 11.3 million did so in the
past year (UNODC, 2019b). Past year use of cannabis among
young people aged 15–16 is high in Europe (13.2 percent),
Oceania (12.4 percent) and the Americas (11.4 percent).
Rates of adolescent cannabis use have declined in Australia
over the past 5–10 years but adolescents who use cannabis
today are more likely to be regular consumers and of lower
socioeconomic status (Chan et al., 2018). Cannabis use is
rising among young people in Europe, the Americas, Africa
and Asia (EMCDDA, 2019; Kraus et al., 2018; UNODC, 2019b).
The proportion of adolescents who believe that cannabis
use poses a risk of harm has decreased over the past decade
in the USA and in Europe (Hasin et al., 2013; Miech et al.,
2017). In a survey of 13,128 people aged 15–24 from the 28
member States of the European Union in 2014, cannabis was
considered the least harmful drug and the easiest to obtain
(TNS Political and Social, 2014; UNODC, 2019b).
Cannabis use disorders affect one in six adolescent
cannabis users (Chandra et al., 2019) and are the most
common drug disorders among people treated in specialist
drug treatment services globally (GBD 2016 Alcohol and Drug
Use Collaborators, 2018; UNODC, 2019b). Regular cannabis
use in adolescence is associated with: lower school attain-
ment and early school dropout (Hall, 2015); poorer cog-
nitive performance (Scott et al., 2018); altered brain in-
tegrity (Lorenzetti et al., 2014, 2016b; Yücel et al., 2016,
2008); depression, anxiety, psychosis and impulse-control
disorders (Moore et al., 2007; Volkow et al., 2016b); and
suicidal ideation (Gobbi et al., 2019).
These findings have heightened significance with the le-
galization of recreational adult cannabis use in 11 states
in the USA and national cannabis legalization in Canada
and Uruguay (UNODC, 2019a). Legalization has increased
adult access to legal cannabis at a lower price and higher
have increased the frequency of cannabis use among young
adults over the legal age of 21 years (Hall et al., 2019;
Hasin et al., 2019). There are conflicting findings to date
on whether cannabis legalization has increased adolescent
use (Hall et al., 2019; Melchior et al., 2019) but it may do
so in the longer term because adolescents under the legal
purchase age will be a target market for illicit sale of legal
cannabis (Sabet, 2007).
We summarize research on the effects of adolescent
cannabis use on brain structure and function, cognitive per-
formance and educational outcomes, as adverse impacts on
these domains can affect life chances and choices of occu-
pation, income and social well-being in adult life.
2. Experimental procedures
Our narrative review summarizes key findings from research pub-
lished in the past 10 years on the brain, cognition and educational
outcomes in cannabis users examined beyond acute intoxication.
Therefore, the emerging findings likely reflect the residual effects
from repeated cannabis exposure. We focus on research on ado-
lescent and young adult samples aged between 14 and 25 years in
accordance with our definition of adolescence as the period corre-
sponding to continued brain maturation (Mills et al., 2016). We use
the term “cannabis users” broadly to encompass the varying def-
initions of cannabis use in these studies, such as heavy and light,
short-term and long-term, occasional and regular cannabis use.
Most often, these studies have defined regular cannabis use in ways
that approximate best to daily or near daily cannabis use. We use
the label “regular” cannabis user to refer to samples of cannabis
users who had engaged in more than occasional cannabis use.
In the following narrative literature review, the following types
of research evidence were included:
1. Reviews of case control studies that compared cannabis users
with non-users for brain and cognitive outcomes measured with
structural and functional neuroimaging tools and standardized
neuropsychological tests.
2. Prospective epidemiological studies of the effects of cannabis
use on cognitive performance in representative cohorts of ado-
lescents followed into their 20 s and early 30 s (e.g. in Dunedin,
Montreal and Bristol) and studies of cognitive performance in
identical twins discordant for cannabis use.
3. Prospective epidemiological studies of the effects of cannabis
use on educational attainment in adolescents.
We also included well-designed studies published since the most
recent systematic review on each topic. Where there were no re-
cent systematic reviews, such as epidemiological studies of cogni-
tive effects of cannabis use, we critically reviewed recent studies.
Adolescent cannabis use, cognition, brain health and educational outcomes: A review of the evidence
3. Results
3.1. Structural neuroimaging studies of cannabis
users
Most structural neuroimaging studies have compared ado-
lescents who are regular cannabis users and non-users
on measures of neuroanatomy (e.g. volumes and thick-
ness of specific brain regions). Neuroanatomical alterations
are thought to take place gradually over extended peri-
ods of time during adulthood, but occur more rapidly dur-
ing adolescent neurodevelopment (Hedman et al., 2012;
Sowell et al., 2003). Neuroanatomical differences between
regular cannabis users and non-users may reflect neuroad-
aptation to the effects of regular exposure to cannabinoids
(Volkow et al., 2017; Zehra et al., 2019).
A recent meta-analysis (Lorenzetti et al., 2019) com-
pared brain volumes between adolescent and adult regular
cannabis users and non-users. It found smaller volumes in
adolescent regular cannabis users than controls in brain re-
gions implicated in learning, memory and stress (i.e., hip-
pocampus), and inhibitory control (e.g. orbitofrontal cor-
tex). Other brain areas did not consistently differ between
regular cannabis users and controls (e.g. overall brain size,
cerebellum, amygdala, striatum, total prefrontal and an-
terior cingulate cortices). A separate review found that
adolescent cannabis users had smaller volumes in the hip-
pocampus and the prefrontal cortex, and altered struc-
tural pathways that connect these regions (i.e., arcu-
ate fasciculus) than non-using controls (Bloomfield et al.,
2019).
In the studies reviewed here, all but one found that ado-
lescent cannabis users also showed consistently larger gray
matter volumes of the cerebellum, one of the brain regions
with the highest concentration of cannabinoid receptors,
than non-users. Increased cerebellar volumes were associ-
ated with poorer executive function in adolescent cannabis
users (Batalla et al., 2013; Blithikioti et al., 2019; Moreno-
Rius, 2019).
A recent narrative review by Chye et al. (2019) also found
that adolescent (but not adult) cannabis use was associated
with altered volume, thickness and surface area in the in-
sula, the cerebellum superior, and the enthorinal, parietal
and frontal cortices.
Jacobus et al. (2019) reviewed two prospective struc-
tural neuroimaging studies. The first followed up 175 ado-
lescent cannabis users after 3 years and the other tested
a separate cohort of adolescents after 6 years. Both sam-
ples had minimal exposure to drugs other than cannabis
and alcohol and alcohol use was included as a covariate.
In one study, continuing cannabis users from 17-to-20 years
had thicker cerebral cortices than non-users and the ef-
fect varied in a dose-dependent fashion (Jacobus et al.,
2015). In the six-year prospective investigations, continu-
ing cannabis users (compared to non-users) from 17 to 20
years had thicker cerebral cortices that varied in a dose-
dependent fashion (Infante et al., 2018; Jacobus et al.,
2016). Larger orbitofrontal volume also predated cannabis
use and predicted regular cannabis use by age 22 years.
Two meta-regressions of these studies (Lorenzetti et al.,
2019; Rocchetti et al., 2013) failed to find significant asso-
ciations between the volumes of selected brain areas (i.e.
171
hippocampus, whole brain size) and duration of cannabis
use. These analyses included studies in both adults and ado-
lescents.
3.2. Functional neuroimaging studies of cannabis
users
Most reviews of functional neuroimaging studies have fo-
cused on the brain function of adolescent cannabis users
during periods of abstinence from cannabis in order to iden-
tify any residual effects of cannabis use on brain function
that indicate possible long-term effects. The measures have
included levels of brain activity in selected brain regions
and connectivity between distinct brain regions.
Systematic reviews have found consistent func-
tional brain alterations in adolescent cannabis users
(Batalla et al., 2013; Blest-Hopley et al., 2018;
Bloomfield et al., 2019; Chye et al., 2019). These have
included both higher and lower activity in prefrontal and
parietal regions during fMRI tasks that assess inhibitory
control (e.g. go-no-go task), reward processing (e.g.
monetary incentive delay task), craving and incentive
salience (e.g. cue reactivity task). A recent meta-analysis
of these fMRI studies (Blest-Hopley et al., 2018) found
that adolescent cannabis users showed larger functional
alterations in brain pathways involved in inhibitory control
(i.e., inferior parietal gyrus) and habitual/compulsive sub-
stance use (i.e., putamen) than non-users. Another review
(Lorenzetti et al., 2016a) found consistent alterations in
the activity of frontal-parietal regions in heavier cannabis
users than in occasional cannabis users. Some studies found
that activity within these regions was correlated with using
higher cannabis doses, longer duration of use, and more
frequent use.
3.3. Case control studies of cognitive
performance
Systematic reviews and meta-analyses have assessed the
residual effects of cannabis on various cognitive domains in
adolescent cannabis users (Broyd et al., 2016; Scott et al.,
2018). A meta-analysis (Scott et al., 2018) compared cog-
nitive performance between cannabis users and non-users
aged up to 26 years. It found impaired performance in the
same cognitive functions in cannabis users that are also con-
sistently different from controls in adult cannabis users,
namely, learning, (delayed) memory, attention and sev-
eral executive functions (abstraction/shifting, inhibition,
updating/working memory, speed of information process-
ing). These alterations were more marked in persons who
sought treatment for cannabis use disorders (Scott et al.,
2018).
Cognitive performance in adolescent cannabis users was
not significantly associated with age of cannabis use onset
and depression symptoms (Scott et al., 2018). Importantly,
cognitive performance in this sample aged up to 26 years
was intact in cognitive domains that consistently differ be-
tween older adult cannabis users and controls, i.e., verbal,
visuospatial and motor performance (Broyd et al., 2016).
172
3.4. Epidemiological studies of the cognitive
effects of cannabis use
3.4.1. Longitudinal studies of intelligence and cannabis
use
Fried et al. (2002) reported an IQ decline in 70 young adults
aged 17–20-years old whose mothers used cannabis during
their pregnancies. They assessed cannabis use by self-report
and urinalysis. They subtracted each person’s IQ measured
at 9–12 years from their IQ at 17–20 years. They then com-
pared IQ changes in current heavy cannabis users (at least
5 joints per week), current light users (less than 5 joints
per week), former users (who had not smoked regularly
for at least 3 months) and non-users (who never smoked
more than once a week and had not used in the past two
weeks). They reported a decrease of 4.1 points in IQ in cur-
rent heavy users and IQ gains in light current users (5.8),
former users (3.5) and non-users (2.6) and no IQ decline
in heavy users who had quit cannabis. They concluded that
cannabis use does not have a permanent adverse impact on
intelligence.
Fried et al. (2005) reported a further follow up of 113
young adults in the same cohort. They assessed overall IQ,
memory, processing speed, vocabulary, attention, and ab-
stract reasoning using a variety of cognitive tests. Cannabis
users were classified by self-report (confirmed by urine tox-
icology analysis) into three groups: light users (< 5 joints
per week), heavy users (greater than or equal to 5 joints
per week) and former light and heavy users who had used
cannabis in the past (greater than or equal to 1 joint per
week) but had not used for at least 3 months. Current heavy
users had significantly lower overall IQs than nonusers, after
accounting for potentially confounding factors and pre-drug
performance. There were lower scores on overall IQ tests,
measured using the full-scale IQ scores of two intelligence
tests, including the Weschler Adult Intelligence Scale (WAIS-
III, for those aged ≥ 16 years), and the Weschler Intelligence
Scale for Children (WISC-III, for those aged < 16 years).
Cannabis users had lower scores in the following IQ in-
dices than nonusers: (i) performance IQ, which measures
overall visuospatial intellectual abilities, and (ii) process-
ing speed, which measures the speed and accuracy of vi-
sual processing. Current heavy users had poorer memory
than nonusers on two indices of the Weschler Memory Scale
(WMS). Specifically, cannabis users had lower scores on the
immediate memory index, which reflects the ability to re-
call information immediately after presentation of verbal
and visual stimuli; and the general memory index, a mea-
sure of delayed memory. Cannabis users performed as well
as nonusers on vocabulary knowledge (Peabody Picture Vo-
cabulary Test), sustained attention, which reflects the abil-
ity to focus on an activity or (visual and auditory) stimu-
lus over a long period of time (Gordon Vigilance Task), and
abstract reasoning, which reflects the ability to form con-
cepts, make non-verbal abstract reasoning and mental flex-
ibility (Category Test). Former cannabis users did not show
any cognitive impairments.
Meier et al. (2012) assessed relationships between
cannabis use and changes in IQ and specific cognitive abil-
ities in 1037 New Zealanders born in Dunedin in 1972 or
1973. They assessed IQ at 13 (before cannabis was used)
and again at 38 years. They asked participants about their
V. Lorenzetti, E. Hoch and W. Hall
cannabis use throughout adolescence and young adulthood.
Early and persistent cannabis users showed an eight-point
decline in IQ compared to peers who had not used cannabis
in this way. This relationship persisted after statistically ad-
justing for alcohol, tobacco and other drug use, schizophre-
nia and educational level. There was recovery in IQ if users
had stopped using cannabis for a year or more by age 38.
Friends and family were more likely to report that persis-
tent daily cannabis users had problems in everyday life with
memory and attention than were the friends and family of
those who had not used cannabis in this way.
Rogeberg (2013) suggested that Meier et al.’s findings may
not be due to cannabis use if participants of low socioeco-
nomic status (SES) were more likely to start using cannabis
at an early age and if low SES users had a faster decline
in IQ. Additional analyses by Moffitt et al. (2013) did not
support his hypothesis. These showed that the IQ decline
was comparable in early and persistent cannabis users from
middle-class homes and that IQ did not decline between
adolescence and young adulthood in lower SES study par-
ticipants.
Mokrysz et al. (2016) investigated associations between
adolescent cannabis use and IQ in 2235 teenagers from
the Avon Longitudinal Study of Parents and Children (AL-
SPC, http://www.bristol.ac.uk/alspac/). They tested rela-
tionships between cumulative cannabis use and IQ at the
age of 15. They found that regular cannabis users had a
lower IQ than their peers and the rate of decline in IQ
was associated with higher cumulative cannabis exposure.
These findings did not persist after they adjusted for to-
bacco smoking and other variables. The authors argued that
cannabis use did not explain the changes in IQ and con-
cluded that cannabis use by teenagers had less effect on IQ
than the Meier et al. (2012) study suggested. They acknowl-
edged that their cohort had many fewer years of regular
cannabis use than had the Dunedin cohort.
3.4.2. Longitudinal cohort studies of the effects of
cannabis use on specific cognitive domains
Tait et al. (2011) evaluated relationships between cannabis
use and specific cognitive domains over 8 years in an Aus-
tralian community sample of 2404 adults first studied at
age 20–24 years. They assessed premorbid verbal IQ, ver-
bal memory (i.e. immediate and delayed recall), working
memory, processing speed, visuospatial processing and at-
tention. They used self-reported cannabis use over three
waves of interviews to define six groups of cannabis users:
‘never’ (n = 420) ‘remain light’ (n = 71), ‘former light’
(n = 231), ‘remain heavy’ (n = 60), ‘former heavy’ (n = 60)
and ‘always former’ since the start of study (n = 657).
The cannabis user groups differed at baseline on verbal
memory (immediate and delayed recall) and a range of ex-
ecutive functions measured by Digit Symbol, such as as-
sociative learning, motor speed, attention, and visuoper-
ceptual functions, including scanning and the ability to
write or draw (i.e., basic manual dexterity) (Jaeger, 2018).
Tait et al. (2011) found no difference between cannabis use
groups and controls on any of the cognitive domains as-
sessed. The only significant difference they found was im-
proved immediate memory recall in former heavy cannabis
users, which persisted after controlling for education and
sex.
Adolescent cannabis use, cognition, brain health and educational outcomes: A review of the evidence
McKetin et al. (2016) reported a follow up of 1897 Aus-
tralians first assessed at 40–46 years of age and followed for
four (94%) and eight years (87%). They assessed the same
cognitive domains as Tait et al. (2011) above. In addition,
at each wave they also assessed simple and choice reaction
time tasks and self-reported cannabis use in the past year
(no use, less than weekly use, weekly use or more). Partici-
pants who used cannabis at least weekly had worse immedi-
ate verbal recall and a trend toward poorer delayed verbal
recall than non-users after adjusting for confounders includ-
ing premorbid verbal ability. There were no significant asso-
ciations between participants’ age and any of the cognitive
performance measures, after controlling for confounders.
Auer et al. (2016) studied the effects of lifetime cannabis
use on cognitive performance in the Coronary Artery Risk
Development in Young Adults (CARDIA https://www.cardia.
dopm.uab.edu/), a prospective cohort study of 3385 adults
followed for 25 years. The cohort was 18–30 years when first
assessed on cognitive tests of verbal memory, processing
speed and selective attention. Nine percent used cannabis
regularly for a substantial part of the follow up. The au-
thors excluded current cannabis users from analyses to en-
sure that they were not intoxicated when their cognitive
performance was assessed. Those with the greatest cumu-
lative exposure to cannabis had the poorest performance
on all cognitive domains. Differences in verbal memory per-
sisted after adjusting for confounders but those in process-
ing speed and selective attention did not. Because there
was no cognitive assessment before cannabis use began, the
authors could not exclude the hypothesis that poorer cogni-
tive performance predated heavier and long-term cannabis
use.
Morin et al. (2019) examined relationships between the
use of alcohol and cannabis and cognitive performance in
young adults in a longitudinal study of 3826 seventh grade
students from 31 schools in the Greater Montreal region.
They examined relationships between year-to-year changes
in alcohol and cannabis use and cognitive performance as-
sessed annually for 4 years. The cognitive domains tested
included delayed recall (i.e. the ability to recall memo-
ries from the past), inhibitory control (i.e. inhibition of
prepotent responses), perceptual reasoning (i.e. the abil-
ity to reason through pictures/visual information), and spa-
tial working memory (i.e. retention of spatial information
over a brief period of time). Spatial working memory was as-
sessed by the “find the phone” task and the spatial working
memory subtest in the Cambridge Neuropsychological Test
Automated Battery. Delayed recall memory was assessed by
a computerized task based on the dot location test of the
Child Memory Scales. Perceptual reasoning was assessed us-
ing items from the Cattell’s Culture Fair Intelligence Test.
Inhibitory control was measured using the passive avoidance
learning paradigm.
Morin et al. (2019) tested four hypotheses. These were:
(1) that cognitive impairment increases the risk of problem
use of cannabis and alcohol; (2) that there is neuroplas-
ticity, i.e. any residual cognitive effects of cannabis and
alcohol use are reversed by abstinence; (3) that there is
neurotoxicity, i.e. regular cannabis and alcohol use cause
long-term residual cognitive impairment that persists after
abstinence; and (4) that there is developmental sensitivity,
i.e. the use of alcohol and cannabis in early adolescence is
173
more likely to produce residual cognitive impairment than
use at older ages.
Morin et al. (2019) found support for a common vulner-
ability model for cannabis and alcohol in all cognitive do-
mains, i.e. adolescents with poorer baseline cognitive per-
formance were more likely to use alcohol and cannabis.
Cannabis, but not alcohol use, also produced effects on in-
hibitory control and working memory that persisted after
abstinence. Cannabis users also showed concurrent resid-
ual impairments in delayed memory recall and perceptual
reasoning. There was some suggestive evidence for a devel-
opmental sensitivity to the cognitive effects of cannabis in
that earlier initiators showed larger impairments. The resid-
ual cognitive effects of cannabis use were larger than those
of alcohol. They were also independent of the effects of
alcohol.
3.4.3. Twin studies of cannabis use and cognitive
function
Lyons et al. (2004) tested for long-term residual effects
of adolescent cannabis use on cognitive performance us-
ing a twin study design. They used this design to determine
whether any cognitive differences between cannabis users
and non-users could be attributed to a genetic vulnerability
that predated adolescent cannabis use or to the effects of
cannabis use. They studied fifty-four monozygotic male twin
pairs from the Vietnam Era Twin Registry (Goldberg et al.,
2002). These twin pairs were discordant for regular cannabis
use and neither twin regularly used any other illicit drugs.
There was a minimum of 1 year since the cannabis-using
twin had last used cannabis and nearly 20 years since they
had last used regularly. Twins were assessed on: general
IQ; verbal memory, logical memory and visual reproduction;
and executive functions such as processing speed, selective
attention, attention, and motor skills.
Twins who used cannabis differed significantly from their
non-using twins in their overall IQ scores. They had a
lower spatial visualization ability and motor skill perfor-
mance measured via the Block Design subtest of the WAIS-
R (Wechsler, 1981), which measures non-verbal reasoning,
analysis and synthesis, visual perception and organization,
and visual–motor coordination. The authors concluded that
there were no marked long-term residual effects of adoles-
cent cannabis use on cognitive abilities because there was
only one significant difference between cannabis-using and
non-using co-twins on cognitive function.
Jackson et al. (2016) examined associations between
cannabis use and IQ in two longitudinal studies of adoles-
cent twins: the Risk Factors for Antisocial Behavior (RFAB)
study of 789 twins, and the Southern California and the Min-
nesota Twin Family Study (MTFS) of 2277 twins. They mea-
sured IQ at ages 9–12 years before cannabis use began and
again at age 17–20 years and used the twin design to con-
trol for the effects of familial factors and genetic propen-
sities. Cannabis users had lower IQ scores than nonusers. In
the period between preadolescence and late adolescence,
cannabis users showed a decrease in crystallised IQ, a mea-
sure affected by knowledge acquired through experience
(i.e. with the Vocabulary and Information subtests of the
WAIS). The authors argued, however, that the IQ decline was
not attributable to cannabis use because there was no rela-
tionship between frequency of use and change in IQ. They
174
concluded that the declines in IQ reflected the effects of
familial factors that predated cannabis use onset and low
IQ.
Meier et al. (2018) used a longitudinal co-twin control
study to test whether poorer cognitive performance pre-
dated cannabis use onset and declined after the onset of
cannabis use. They studied 1989 twins from the Environmen-
tal Risk Longitudinal Twin Study (E-Risk, http://eriskstudy.
com/), a birth cohort of twins born in England and Wales
from 1994 to 1995. They measured frequency of cannabis
use and cannabis dependence at age 18 years (DSM-IV crite-
ria) and assessed IQ at 5, 12 and 18 years. Executive func-
tions were assessed at age 18 along with attention and work-
ing memory, vigilance and spatial working memory.
Adolescents who used cannabis had a lower IQ in child-
hood than peers who did not as well as a lower IQ at age 18.
The frequency of their cannabis use was not associated with
an IQ decline between 12 and 18. Adolescents who were
cannabis dependent at age 12 and age 18 had IQ scores that
were 5.6 and 7.4 points lower than adolescents who were
not dependent. However, those who were cannabis depen-
dent did not show a greater decline in IQ between 12 and
18.
Adolescents who used cannabis had poorer executive
functions at age 18 than adolescents who did not use
cannabis, but they did not find these associations within
twin pairs. For example, twins who used cannabis more fre-
quently than their co-twin did not differ on four of the six
tests of executive function (all but rapid visual process-
ing test, total false alarms; and total errors at the spa-
tial working memory). After controlling for IQ at age 12
years, performance on executive tasks was impaired only
on measures of attention and working memory. Importantly,
twins who used cannabis more frequently than their co-
twin performed worse on a working memory test (CANTAB)
(Sahakian et al., 1988). Meier et al. (2018) concluded that
short-term or dependent cannabis use in adolescence does
not appear to cause a decline in IQ or impair executive func-
tions. Instead, family background explained why adolescent
cannabis users perform worse on IQ and executive function
tests than non-users.
3.4.4. Longitudinal studies of educational outcomes
and cannabis use
Macleod et al. (2004, 2005) reported a systematic review of
the effects of adolescent cannabis use that included educa-
tional attainment as an outcome. They found that cannabis
use was consistently associated with reduced educational
attainment but argued that the relationship was unlikely
to be causal because its magnitude was attenuated after
controlling for potential confounders (e.g. childhood adver-
sity, and factors that relate to the peer group and family).
They acknowledged that they could not exclude the hypoth-
esis that cannabis exposure may have caused poor education
outcomes.
Townsend et al. (2007) also reported a synthesis of the
findings of longitudinal studies of associations between the
frequency of early cannabis use and dropping out of school
(Brook et al., 1999; Ensminger et al., 1996; Fergusson and
Horwood, 1997; Fergusson et al., 2003, 1996; Green and En-
sminger, 2006). They found only one study (Ellickson et al.,
1998) in which cannabis use was no longer a significant
V. Lorenzetti, E. Hoch and W. Hall
predictor of dropping out of school after controlling for
confounding variables (e.g. age, gender, family structure,
school-related factors).
Horwood et al. (2010) assessed the association between
age of onset of cannabis use (<15, 15–17, never before
age 18) and educational achievement /high school com-
pletion, university enrolment, and degree attainment in
three Australasian cohort studies with over 6000 partici-
pants (Fergusson and Horwood, 2001; Najman et al., 2005;
Swift et al., 2008). These studies accounted for a broad
range of confounders, such as family socio-demographic
background; child cognitive ability and educational achieve-
ment prior to the onset of cannabis use; measures of family
functioning and measures of child and early adolescent be-
havioral adjustment.
Both the individual studies and their pooled results
showed that the later the age of first cannabis use the
greater an adolescent’s educational achievement. By com-
parison with adolescents who first used cannabis before age
15, those who had never used cannabis by age 18 were 2.4–
4.1 times more likely to complete high school. The odds
of university enrolment were 1.8–2.9 times greater and the
odds of degree attainment were 3.0–4.4 times greater. After
controlling for the confounders, adolescents who had not
used cannabis by age 18 were 1.9–2.9 times more likely to
have higher educational achievement than those who began
using cannabis before age 15. The authors estimated that
the early age of cannabis use onset explained up to 17% of
the variance in failure to complete high school, enroll in
university and attain a university degree.
Friemel (2019) reviewed systematic reviews of studies
of cannabis and educational outcomes (Horwood et al.,
2010; Townsend et al., 2007) and other social consequences
(Macleod et al., 2005, 2004). Like Townsend et al. (2007),
Friemel found a consistent association between recent
cannabis use and early school dropout (Aloise-Young and
Chavez, 2002; Eggert and Herting, 1993; Gfroerer et al.,
1997; Zimmerman and Maton, 1992).
3.4.5. Twin studies of educational outcomes
Grant et al. (2012) used twin study data to test whether
alcohol, nicotine, and illicit drug (including cannabis) use
and dependence were associated with lifetime educational
attainment after controlling for familial background. Data
came from a 1987 questionnaire survey and a 1992 tele-
phone diagnostic interview with 6242 male twins (n = 3121
pairs; mean age = 41.9 years in 1992) who served in the
U.S. military during the Vietnam era. They examined rates
of completion of 16 years of education in twin pairs who
were discordant for early alcohol and cannabis use, daily
nicotine use, lifetime cannabis use, and alcohol, nicotine,
cannabis, and any illicit drug dependence. Twins who used
alcohol before age 18, who had a lifetime alcohol depen-
dence diagnosis, and who had used nicotine daily for 30 or
more days were less likely to complete 16 years of education
than twins who had not. The twin pairs who were discordant
for cannabis initiation, early cannabis use, or cannabis de-
pendence did not differ in educational outcomes.
Verweij et al. (2013) used data from a large commu-
nity sample of 3337 adult twins to determine whether ge-
netic and/or environmental influences explained the rela-
tionship between adolescent cannabis use before age 18 and
Adolescent cannabis use, cognition, brain health and educational outcomes: A review of the evidence
a failure to complete secondary school. They found a sig-
nificant correlation between early-onset cannabis use and
early school dropout. Their co-twin control design, however,
could not rule out the hypothesis that the correlation was
explained by shared environmental factors.
3.4.6. A cannabis policy experiment in the Netherlands
Marie and Zölitz (2017) reported a natural experiment that
took advantage of a change in the regulation of Dutch cof-
fee shops to assess the effects that cannabis use had on
students’ performance in economics and business courses.
In order to reduce drug tourism the city of Maastricht in
the Netherlands decided to restrict the nationality of stu-
dents who could purchase cannabis in coffee shops in the
city. Students from the Netherlands, Belgium and Germany
could access coffee shops while students from France and
Luxembourg could not. Coffee shops enforced the policy by
requiring students to show their identification cards before
they entered.
Marie and Zölitz (2017) used a difference-in-difference
analysis to examine any changes before and during the cof-
fee shop restrictions in the grades in students from these
different countries who were enrolled in the School of Busi-
ness and Economics at Maastricht University. They found
that the academic performance of students who could no
longer legally buy cannabis in coffee shops improved 0.10
of a standard deviation and their pass rates improved by
5%. They found larger improvements in performance (i.e.
10% increase in pass rates) in younger students, in female
students and in students who had performed poorly ear-
lier in the course. The gains were 3.5 times greater in
courses that required numerical/mathematical skills. Stu-
dent course evaluations suggested that these gains reflected
an improved understanding of the course material rather
than changes in the students’ study habits. The authors ar-
gued that their study may have under-estimated the effects
of the restricted access to coffee shops if students from
France and Luxembourg purchased cannabis illicitly from
other students who were able to purchase cannabis.
4. Discussion
We briefly review the major findings in each of the research
domains, draw some provisional conclusions and identify
priorities for future research in each area.
4.1. The evidence from neuroimaging studies
The neuroimaging evidence suggests that adolescent
cannabis use is associated with alterations in the structural
integrity of prefrontal and medial temporal brain regions
and thicker cortices. Fewer studies of adolescent cannabis
users and controls found smaller volumes in the hippocam-
pus and orbitofrontal cortex than similar comparisons of
adult cannabis users and non-using controls. This suggests
that neuromaturation in adolescence may moderate any ef-
fects of cannabis use on the developing brain. None of the
meta-regression found significant associations between du-
ration of use and brain volumes, including in the adolescent
samples examined (Rocchetti et al., 2013). These analyses
175
were limited by the small sample size of the studies and by
the fact that only a minority of studies reported the dura-
tion of cannabis use.
Functional brain alterations have been most consistently
found in the parietal cortex and putamen. There were no al-
terations in adolescent users’ behavioural performance dur-
ing the fMRI tasks so their altered brain activity may re-
flect compensatory strategies used to achieve normal per-
formance.
Overall, the systematic reviews and meta-analyses of
structural and functional neuroimaging case-control stud-
ies have found that adolescent cannabis use is associated
with alterations in the structure of prefrontal and temporal
brain regions, and with functional alterations in the parietal
cortex and putamen. It remains uncertain to what degree
these changes are causes or consequences of cannabis use
because emerging developmental evidence indicates that
some neuroanatomical alterations predate and predict reg-
ular cannabis use (Cheetham et al., 2012; Chye et al., 2017;
Jacobus et al., 2019; Wade et al., 2019).
4.2. Case control studies of cognitive functioning
Studies comparing performance on selected cognitive do-
mains in cannabis using adolescents and controls have pro-
duced mixed findings. Participants’ age may moderate the
association between cognitive performance and cannabis
use (Gorey et al., 2019; James et al., 2013). Adult cannabis
users over the age of 25 years have not been included in
the most recent meta-analyses and reviews (Gorey et al.,
2019; Scott et al., 2018) so it is unclear if participants’
age moderates any effects of cannabis use on cognition
(Duperrouzel et al., 2019; Gorey et al., 2019).
Meta-analyses of the cognitive performance of adoles-
cent cannabis users show more consistently impaired per-
formance while adolescents continue to use cannabis. These
cross sectional studies have the same limitations as the neu-
roimaging studies, namely, difficulty in deciding whether
the differences observed are causes or consequences of
cannabis use. Nonetheless, the fact that regular cannabis
users show cognitive recovery after prolonged abstinence
provides some support for the hypothesis that regular
cannabis use in adolescence impairs cognitive performance
while users are not acutely intoxicated
4.3. The epidemiological evidence
Several of the longitudinal studies have found a larger de-
cline in IQ among cannabis users than in their non-using
peers (Fried et al., 2002; Meier et al., 2012; Mokrysz et al.,
2016) while twin studies have found that twins who used
cannabis had a lower IQ than the non-using twins. It is
uncertain whether these IQ declines reflect the effects of
cannabis use because these results did not always persist
after controlling for confounders (e.g. SES, tobacco use).
In the Mokrysz et al. (2016) study, for example, the IQ dif-
ference was no longer significant after controlling for the
effects of tobacco smoking. In the Meier et al. (2012) study,
by contrast, the difference persisted after controlling for
potential confounders. The twin studies suggest that the IQ
176
differences could be explained by shared genetic and en-
vironmental risk factors (Jackson et al., 2016; Meier et al.,
2018). Several longitudinal studies have reported a recovery
in IQ (and performance on specific cognitive tests) if reg-
ular cannabis users become abstinent (Meier et al., 2018;
Tait et al., 2011). This finding is consistent with the findings
of meta-analyses of studies comparing cannabis users and
non-using controls.
The interpretation of the epidemiological studies is com-
plicated by the fact that different studies have assessed
different cognitive domains and used different measures
within these domains. Studies have most often used IQ, ver-
bal and non-verbal memory, attention, and executive func-
tions. The samples have also varied greatly in the preva-
lence of daily cannabis use (the pattern most often asso-
ciated with cognitive impairment in case-control studies).
They have also differed in the period over which they have
assessed cognitive performance, from as little as 2 years to
as many as 27 years.
A major limitation of the epidemiological cohort stud-
ies is that most samples only include a small proportion of
cannabis users who have used regularly for sustained peri-
ods. A substantial proportion of daily cannabis users cease
using cannabis in their late 20s and there is often a higher
rate of loss to follow up among regular cannabis users that
may bias epidemiological studies against finding any cogni-
tive effects of regular cannabis use.
Twin studies have also included relatively small numbers
of twins who were discordant for cannabis use. Their as-
sessments of cognitive performance have often been limited
to minimize respondent burden and the self-report data on
cannabis use has often been retrospective. This may mean
that twins who were classified as regular cannabis users (on
the basis of a lifetime history of cannabis use) have often
ceased using cannabis when cognitively assessed. This type
of misclassification would reduce the ability of twin studies
to detect cognitive effects of cannabis use.
A more consistent finding in longitudinal studies and twin
studies is that cannabis users are less likely to complete
secondary school or to graduate from college than their
peers who do not use cannabis. In the majority of studies,
cannabis users were more likely to perform poorly on exam-
inations at the end of secondary school or in university. It
remains uncertain whether this association reflects an ad-
verse effect of cannabis use (e.g. via impaired cognitive
performance, poor study skills or impaired motivation) or
uncontrolled differences between cannabis users and their
peers that affect their chances of completing school. Con-
trolling for potential confounders, such as other drug use
(especially tobacco smoking) and conduct disorder in child-
hood, has often attenuated but not eliminated the associa-
tions.
4.4. Some cross cutting findings
A number of similar findings have emerged from the differ-
ent types of research design that are worth noting.
The first is evidence that poorer neural integrity, cogni-
tive performance and educational outcomes predate the on-
set of cannabis use and appear to increase the risk of the ini-
tiation and regular cannabis use. A small number of longitu-
V. Lorenzetti, E. Hoch and W. Hall
dinal neuroimaging studies also suggest that neuroanatomi-
cal differences in the orbitofrontal cortex predate and pre-
dict early cannabis use. Longitudinal and twin studies sug-
gest that young people with poorer executive function, in-
hibitory control and memory are more likely to become reg-
ular cannabis users than their non-using peers (Morin et al.,
2019; Tait et al., 2011).
A second finding is the evidence of cognitive recovery
in regular cannabis users after sustained abstinence. Absti-
nence from cannabis appears to improve performance on IQ
and cognitive tests and there is suggestive evidence that the
degree of improvement increases with the duration of ab-
stinence. These findings suggest that regular cannabis users
are cognitively impaired while they are using cannabis but
their cognitive functioning may recover after they cease
using. There are too few studies with sufficient statistical
power to assess whether smaller, longer-term residual cog-
nitive effects have gone undetected.
The few studies that have examined changes in
brain structure and function among abstinent regu-
lar cannabis users find some suggestion of recovery.
Yücel et al. (2016) observed hippocampal volume alter-
ations in current adult cannabis users but not among heavy
former users who had been abstinent for 2.4 years. This sug-
gests that brain integrity in cannabis users may also recover
after sustained abstinence.
4.5. How significant is cognitive impairment in
cannabis users?
It is difficult to decide between a number of interpretations
of the associations found between cannabis use in adoles-
cence and measures of brain integrity, poor cognitive per-
formance and education attainment.
The first possibility is that the association between
cannabis use in adolescence and poor cognitive perfor-
mance in adulthood is wholly due to selection effects. That
is, young people with poorer cognitive ability are more
likely to initiate cannabis use at an early age, become reg-
ular cannabis users and persist in using cannabis through-
out adulthood. As noted, there is evidence from longitudi-
nal and neuroimaging studies that young people who initi-
ate cannabis use early do perform more poorly in school in
late childhood than peers who do not use cannabis. Many of
the longitudinal studies also find that the relationship be-
tween cannabis and poor performance cognitive outcomes
persists, albeit with attenuation, after statistical adjust-
ment for differences in baseline cognitive performance. A
plausible hypothesis that needs to be more rigorously tested
is that regular adolescent cannabis use worsens cognitive
performance in poorly performing students and increases
their likelihood of failing to complete secondary school.
Second, the everyday impact of the residual cognitive
impairments (assessed beyond acute intoxication) has not
been systematically assessed in most studies. There are
nonetheless suggestions that these cognitive changes may
have an adverse effect on the lives of a significant minor-
ity of young people. In the study of Meier et al. (2012),
for example, family and friends noticed deficits in the daily
cognitive performance of regular cannabis users. The study
of the AVON cohort also found significant differences in
Adolescent cannabis use, cognition, brain health and educational outcomes: A review of the evidence
performance on secondary school examinations between
regular and nonregular users (Mokrysz et al., 2016).
Marie and Zölitz (2017) found that university course grades
improved more in students who were not able to purchase
cannabis in coffee shops in Maastricht than in their peers
who could still purchase cannabis.
Third, some authors suggest that the cognitive impair-
ments associated with regular cannabis in adolescence are
of minimal significance because they recover after 4-to-6
weeks of abstinence (Scott et al., 2018). This assumption
is arguable because many adolescents who become regu-
lar cannabis users find it difficult to quit in adulthood af-
ter a decade of daily use, possibly because neuroadapta-
tion occurs with heavy regular use (Volkow et al., 2016a;
Zehra et al., 2018). Even if these cognitive changes do
recover with abstinence, daily intoxication during adoles-
cence and young adulthood may impair educational attain-
ment and this may limit a young person’s choice of occupa-
tion after leaving school, lower their incomes, and reduce
their chances of forming satisfying long-term personal rela-
tionships in later life (Fergusson and Boden, 2008).
4.6. Advice for adolescents and young adults
about cannabis use
The cognitive effects of cannabis require further research
but adolescents should nonetheless be informed that there
may be adverse cognitive, neural and educational effects
from daily cannabis use. Adolescents and young adults who
use cannabis should also be informed about cognitive recov-
ery after cessation of daily use. This could encourage ces-
sation in regular users who are concerned about the effects
of cannabis on their cognitive performance. This type of ad-
vice could be given as part of information about other risks
of daily cannabis use of potent cannabis products, namely
cannabis dependence and the possible precipitation and ag-
gravation of psychoses, anxiety and depression (Hall, 2015).
4.7. Priorities for future research
We make the following recommendations for future re-
search on the residual and other cognitive effects of
cannabis use in adolescence and young adulthood.
First, studies should use standardized methods to mea-
sure IQ and executive function, childhood adversity, edu-
cation and occupation, SES and family history. The use of
the same measures of these key variables will facilitate the
integration of findings from neuroimaging, epidemiological
and cognitive studies.
Second, standardized measures need to be used of
cannabis use, cannabis potency and cannabis routes of ad-
ministration. These should include frequency and quantity
of cannabis use, age of first use and symptoms of cannabis
dependence. These data are essential to assess the cogni-
tive, brain and educational effects of recent increases in
cannabis potency and the diversification of cannabis prod-
ucts.
Third, cognitive, education and brain outcomes should be
assessed at different ages, before and after puberty stage
and in both sexes. Studies should also assess mental health
177
variables (e.g. depression, anxiety and psychotic symptoms)
that may moderate adverse outcomes in the most vulnera-
ble young cannabis users.
Role of funding source
No funding source played a role in preparing this paper or
deciding whether to publish.
Contributors
Dr. Valentina Lorenzetti, School of Behavioural and Health
Sciences, Faculty of Health Sciences, Australian Catholic
University, Australia
Dr Eva Hoch, Cannabinoid Research and Treatment Group,
Department of Psychiatry and Psychotherapy, University
Hospital, and Division of Clinical Psychology and Psycholog-
ical Treatment, Department of Psychology, Ludwig Maximil-
ian University Munich, Germany,
Professor Wayne Hall, center for Youth Substance Abuse
Research, The University of Queensland, Australia
17 Upland Road, St Lucia QLD 4072 and the National Ad-
diction center, Kings College London, United Kingdom
Conflict of Interest
None of the authors has any conflict of interest to declare.
Acknowledgment
We would like to thank Sarah Yeates for her assistance in
preparing this paper for publication.
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