RESEARCH REPORT doi:10.1111/add.

15472

Trends in cannabis use among adults with children in the

home in the United States, 2004–2017: impact of state-
level legalization for recreational and medical use

Renee D. Goodwin1,2 , June H. Kim3, Keely Cheslack-Postava4, Andrea H. Weinberger5,6,

Melody Wu1,2, Katarzyna Wyka7 & Meyer Kattan8,9
Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY, USA,1 Department
of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA,2 Institute for Implementation Science in Population Health, The City
University of New York, New York, NY, USA,3 Department of Psychiatry, Columbia University, New York, NY, USA,4 Ferkauf Graduate School of Psychology,
Yeshiva University, Bronx, NY, USA,5 Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA,6 Center for Systems
and Community Design, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY, USA,7 Department of Pediatrics, New
York-Presbyterian/Columbia University Medical Center, New York, NY, USA8 and Division of Pediatric Pulmonology, New York-Presbyterian/Morgan Stanley
Children’s Hospital, New York, NY, USA9

ABSTRACT

Background and Aims Cannabis use among parents may be increasing with legalization, but perception of associated
risk has declined. The study investigated the association between cannabis legalization and cannabis use among adults
with children in the home over time in the United States (US). Design A difference-in-difference approach was applied
to public and restricted-use data from the 2004–2017 National Survey on Drug Use and Health (NSDUH), an annual
cross-sectional survey. Setting A representative sample of the United States. Participants/Cases Respondents ages
18+ with children living in the home drawn from the NSDUH (n = 287,624), which is administered to non-institutional-
ized civilians in the 50 states and District of Columbia. Measurements Exposures were year and state-level cannabis pol-
icy in state of residence annually. Outcomes were past-30-day cannabis use and daily cannabis use. Sociodemographic
variables included age, gender, marital status, annual family income, race/ethnicity, educational attainment, and strength
of state-level tobacco control. Findings In 2017, past-month cannabis use (11.9%, 9.3%, and 6.1%) and daily cannabis
use (4.2%, 3.2%, and 2.3%) were more common in states with recreational marijuana laws (RML), followed by states with
medical marijuana laws (MML) and without legal cannabis use, respectively. RML and MML were associated with signifi-
cantly higher prevalence of past-month cannabis use (adjusted odds ratio [AOR] = 1.28, 95% confidence interval
[CI] = 1.12–1.46; AOR = 1.12, 95% CI = 1.03–1.22) and daily cannabis use (AOR = 1.25, 95% CI = 1.03–1.51;
AOR = 1.16, 95% CI = 1.02–1.32), respectively. The impact of MML was particularly salient among adults ages 50+ and
the highest income and education subgroups. Conclusions Among adults with children living in the home, cannabis
use appears to be more common in US states with legalized cannabis use compared with states with no legal cannabis
use. Recreational legalization appears to increase use among adults with children in the home broadly across nearly all
sociodemographic groups, whereas the effect of legalization for medical use is heterogeneous by age and socioeconomic
status.

Keywords Cannabis, epidemiology, legalization, marijuana, NSDUH, substance use.

Correspondence to: Renee D. Goodwin, Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Rm 1030D,
New York, NY 10032. E-mail: rdg66@columbia.edu
Submitted 9 June 2020; initial review completed 1 September 2020; final version accepted 24 February 2021

INTRODUCTION primary source of child secondhand smoke (SHS) exposure

[2,3], and youth exposure to secondhand tobacco smoke
More than one in three (34.4%) children in the United (STS) has well-documented health consequences [4].
States (US) live in a household with at least one adult Extensive public health and clinical intervention efforts
cigarette smoker [1]. Residential parental smoking is the have led to lowered cigarette smoking among adults overall

© 2021 Society for the Study of Addiction Addiction, 116, 2770–2778


in the US, and increased enactment of smoke-free laws has
reduced exposure to STS among adults and youth in both
public and private spaces [4–6]. Although cigarette
smoking is decreasing, cannabis use is simultaneously in-
creasing among adults in the US [7–9], with recent data
suggesting that increases in cannabis use are more rapid
in states that have legalized cannabis for recreational (rec-
reational marijuana laws, RML) and/or medical (medical
marijuana laws, MML) use [10], especially among individ-
uals already using cannabis [11]. Child exposure to sec-
ondhand cannabis smoke (SCS) also appears to be
associated with potential harms to respiratory health
[12,13].
With legalization, perception of risk associated with
cannabis use has declined rapidly [8,14,15]. Therefore, in
contrast with cigarette use, cannabis use among parents
may be increasing, whereas awareness or concern over
risks associated with exposure to SCS possibly remains lim-
ited. It is not known whether legalization for medical and/
or recreational use has impacted cannabis use among
adults with children in the home. Increased exposure could
theoretically thwart the public health gains achieved in re-
ducing child exposure to SHS. In addition, parental canna-
bis use is associated with increased risk of cannabis use
among offspring [16].
If legalization for medical or recreational purposes has
led to increases in cannabis use among adults living in
the home with children, increased attention to public
health education programs addressing potential risks of
SCS exposure and parental cannabis use to youth should
be considered. Interventions and programming in commu-
nity and clinical settings can provide advice on how to min-
imize youth exposure to SCS, as has been done with adult
cigarette use and youth exposure to STS. Further, recent
data demonstrated differences in the prevalence of canna-
bis use among parents with children in the home by demo-
graphics [9]. It is not known whether changes in cannabis
use among adults with children in the house by cannabis
legalization in their state of residence differ among demo-
graphic subgroups. Understanding these patterns and
trends can facilitate targeting of vulnerable populations
and intervention resources.
The goal of the current study was to address these gaps
in knowledge of this timely and urgent public health issue
by investigating cannabis use among adults with children
living in the home in the US. We hypothesize that the prev-
alence of past-month current and daily cannabis use is
higher among those residing in states in which cannabis
use is legal than in states without any cannabis legaliza-
tion. First, the study estimated the prevalence of
past-month current and daily cannabis use among adults
with children living in the same home in the US, by state-
level cannabis legalization status in 2017, overall and by
sociodemographic characteristics. Second, the study
© 2021 Society for the Study of Addiction
Cannabis use in adults with children at home 2771
estimated the relationship between MML/RML adoption
and the odds of past-month current and daily cannabis
use among adults with children in the home in the US.
METHODS
Data and population
Public and restricted-access data from the 2004 to 2017
National Survey on Drug Use and Health (NSDUH) were
used. The NSDUH is an annual cross-sectional, nationally
representative survey on substance use and mental health
in the US. Weighted interview response rates for 2004 to
2017 ranged from 66.5% to 77.0%. Data are collected an-
nually from male and female civilian non-institutionalized
persons ages 12 and older in each of the 50 US states and
the District of Columbia. The analysis was not
pre-registered on a publicly available platform, and the re-
sults should be considered exploratory.
Information about state of residence was used to
determine state MML and RML status and these data,
which are restricted-use variables, were accessed through
the Research Data Center. Data collection for the NSDUH
was approved by the National Center for Health Statistics
(NCHS) Research Ethics Review Board (ERB). Analysis of
de-identified data from the survey is exempt from federal
regulations for the protection of human research partici-
pants. Analysis of restricted data through the NCHS
Research Data Center was also approved by the NCHS
ERB. Our sample was restricted to adult respondents (ages
18 and older) who reported having children ages
<18 years living in the home (n = 287,624), and a sub-
sample of the 2017 NSDUH respondents with the same
characteristics (n = 22,308). Data were pooled for survey
years 2004 to 2017 (long format).
Measures
Current cannabis use
Respondents were asked about their past-month use of
cannabis or hashish. Past-month cannabis use was
classified as use of cannabis on at least 1 day in the past
30. Respondents were classified as daily cannabis users if
they reported using on 30 of the past 30 days.
Sociodemographic characteristics
To control for individual- and state-level factors that may
confound or moderate the association between cannabis
legalization and current cannabis use, estimates were
adjusted for the following covariates; individual age (18–
25, 26–34, 35–49, ≥50 years old), gender (male, female),
marital status (married, widowed/divorced/separated,
never married), annual family income (<$20,000,
$20, 000–$74,999, ≥$75,000), race/ethnicity (non-
Addiction, 116, 2770–2778
2772 Renee D. Goodwin et al.
Hispanic White, non-Hispanic Black, Hispanic, non-His-
panic Other), educational attainment (less than high school,
high school or equivalent, some college, college graduate or
above), and strength of state-level tobacco control.
Cannabis legalization
Cannabis legalization was defined by the presence of
enacted MML or RML. The time-varying indicators for
MML and RML were “0” in years before enactment, and
“1” for all subsequent years and for MML and RML, respec-
tively (states can be “1” for MML and “1” for RML within
the same year). Comparison states were states without
cannabis legalization during the study period (AL, GA,
IA, ID, IN, KS, KY, MS, NC, NE, OK, SC, SD, TN, TX, UT,
VA, WI, and WY).
Statistical analysis
First, among adults with children in the home, we esti-
mated the prevalence of past-month cannabis and
past-month daily cannabis use by the cannabis legalization
status of their state of residence in 2017. The cannabis le-
galization groups include states with RML and MML in
2017 (AK, CA, CO, DC, MA, ME, NV, OR, and WA), states
with only MML in 2017 (AR, AZ, CT, DE, FL, HI, IL, LA,
MD, MI, MN, MO, MT, ND, NH, NJ, NM, NY, OH, PA, RI,
VT, and WV), and states with no legalization in 2017
(AL, GA, IA, ID, IN, KS, KY, MS, NC, NE, OK, SC, SD, TN,
TX, UT, VA, WI, and WY).
Second, we attempted to visually inspect the
parallel trends assumption, which assumes that the pre-
intervention trends in exposed and unexposed groups are
parallel. To this end, we first categorized states into four
fixed groups based on their RML/MML status in 2018,
which is the most recent year of NSDUH data availability
(having passed MML early in the study period, i.e. 2004–
2011, or post 2011; having ever passed RML; no MML/
RML in the study period). States that had passed MML be-
fore versus after 2011 were categorized separately because
of observed heterogeneity based on duration of passage
[17]. Next, for every calendar year between 2004 (the first
available year) and 2013 (the first year in which RML was
passed); the prevalence of each outcome (i.e. past-month
cannabis use, past-month daily cannabis use) was esti-
mated (see Supporting information Figs. S1a and S1b).
Third, we assessed the impact of both medical and rec-
reational cannabis legalization on current cannabis use
among adult respondents living with children in the house-
hold using difference-in-difference (DiD) models using lo-
gistic regression for binary outcomes. The DiD method
estimates the effect of legalization by comparing changes
in the outcome (i.e. cannabis use, daily cannabis use) from
before to after passage of a law in states passing laws com-
pared to the changes over the same time period in states
© 2021 Society for the Study of Addiction
whose legalization status remained stable. This is done by
including fixed effects for state of residence and for calendar
year along with time-varying indicators for the presence of
MML and RML. Hence, separately for each cannabis out-
come, two-way fixed effect models that included calendar
year and state of residence, time-varying indicators for
MML and RML (unadjusted model), as well as
sociodemographic covariates and state-level tobacco con-
trol (adjusted model) were estimated. DiD estimates
(expressed as adjusted odds ratios [AORs]) are only reflec-
tive of states that have changed status within the study pe-
riod. Therefore, only states that have a status change for
MML (from “0” indicating no legalization to “1” indicating
legalization) are included among the MML “treated” group
(AZ, AK, CT, DC, DE, FL, IL, LA, MA, MD, MI, MN, MO, ND,
NH, NJ, NM, NY, OH, OK, PA, RI, UT, VT, and WV). Simi-
larly, only states that have a status change for RML (from
“0” to “1”) are included among the RML “treated” group
(AK, CA, CO, DC, MA, ME, NV, OR, and WA). All other
states contribute as “controls” and are used to estimate
the “counterfactual” trend that treatment states would
have demonstrated had they not been “treated” (i.e.
changes in the outcomes over the same time period in
states that did not pass MML or RML). The AOR indicates
the change in the odds of cannabis use over time in states
where MML/RML were enacted compared to states with-
out MML/RML enactment.
Fourth, heterogeneity in DiD estimates across
sociodemographic strata was explored by including inter-
action terms between the sociodemographic factor of inter-
est and time-varying indicators for RML and MML (i.e. two
separate two-way interactions, with no interaction be-
tween MML and RML). Interactions between MML/RML
and each sociodemographic factor were explored one fac-
tor at a time (e.g. age*MML + age*RML), and adjusted in-
teraction models included the other un-interacted,
sociodemographic factors. Stratum-specific DiD estimates
were obtained using the “effects” command. The P value
for the interaction term (denoted P_int in the tables) indi-
cates whether the strength of association varies between
a specific sociodemographic group versus the reference
group. All analyses were conducted using SAS-callable
SUDAAN version 11.0.1 and incorporated survey weights
for all analyses. P values <0.05 were considered statisti-
cally significant.
RESULTS
Prevalence of current cannabis use in 2017
The prevalence of past-month cannabis use among adults
with children living in the household varied by cannabis le-
galization status in 2017 (Table 1a), such that past-month
prevalence was highest among adults residing in states
with RML (11.9%), followed by states with MML (9.4%)
Addiction, 116, 2770–2778
 Cannabis use in adults with children at home 2773

Table 1 (a) Prevalence of past-month cannabis use among adults with children <18 years in the household by cannabis legalization
status and sociodemographic characteristics, NSDUH 2017.

Cannabis legalization status

a a a
No MML (n = 7500) MML (n = 10,800) RML (n = 3900)

Overall 600 (6.11%) 1300 (9.44%) 600 (11.91%)

Age
18–25 300 (13.24%) 500 (19.74%) 300 (19.87%)
26–34 200 (7.47%) 300 (10.86%) 100 (15.27%)
35–49 100 (4.53%) 400 (7.59%) 200 (10.01%)
≥50 <100 (2.13%) <100 (4.44%) <100 (6.42%)
Gender
Male 300 (7.88%) 600 (11.67%) 300 (14.69%)
Female 300 (4.69%) 600 (7.62%) 300 (9.65%)
Marital status
Married 200 (3.37%) 400 (5.87%) 200 (8.61%)
Widowed/divorced/separated <100 (6.77%) 100 (8.10%) <100 (10.47%)
Never married 400 (13.07%) 800 (17.77%) 400 (20.92%)
Income
<$20,000 100 (8.79%) 300 (14.11%) 100 (16.63%)
$20,000–$74,000 200 (7.79%) 400 (10.04%) 200 (13.48%)
≥$75,000 200 (4.61%) 500 (8.07%) 300 (10.32%)
Race/Ethnicity
Non-Hispanic White 300 (6.26%) 700 (9.91%) 300 (15.61%)
Non-Hispanic Black 100 (8.27%) 200 (12.77%) <100 (20.23%)
Hispanic <100 (3.92%) 200 (7.02%) 200 (8.43%)
Non-Hispanic Other <100 (5.91%) 100 (5.63%) <100 (7.21%)
Education
Less than high school 100 (8.25%) 200 (11.17%) 100 (10.05%)
High school or equivalent 200 (7.44%) 400 (11.09%) 200 (13.46%)
Some college 200 (7.44%) 500 (10.68%) 200 (15.18%)
College graduate or above <100 (2.51%) 200 (6.24%) 100 (9.26%)

a
MML = medical marijuana laws; NSDUH = National Survey on Drug Use and Health; RML = recreational marijuana laws. Unweighted sample sizes must be
rounded to the nearest 100 to use NSDUH restricted-use data in the Research Data Center setting.

and then states with neither MML nor RML (6.1%). The
prevalence of past-month cannabis use decreased with in-
creasing age, was higher among males, those who never
married, those who reported a family income less than
$20,000 and non-Hispanic Black individuals.
Similarly, the prevalence of past-month daily cannabis
use also varied by cannabis legalization status (Table 1b),
with the highest prevalence of daily cannabis use reported
among adults residing in states with RML (4.2%), followed
by states with MML (3.2%) and then states with neither
MML nor RML (2.4%). The prevalence of daily cannabis
use was higher among younger age groups, males, those
who never married, those who reported a family income
less than $20,000 and non-Hispanic Black individuals.
Difference-in-difference estimates for past-month any
cannabis use (Table 2a)
Overall, both medical cannabis (AOR = 1.12, 95% confi-
dence interval [CI] = 1.03–1.22) and recreational canna-
bis legalization (AOR = 1.28, 95% CI = 1.12–1.46) were
associated with increases in past-month cannabis use
among adults with children in the household, compared
with states that did not have legalized marijuana during
the study period.
The association between MML and past-month
cannabis use significantly varied by age (F(3) = 8.43,
P < 0.001), marital status (F(2) = 4.62, P = 0.010), in-
come (F(2) = 3.23, P = 0.040), race/ethnicity
(F(3) = 7.85, P < 0.001) and education (F(3) = 11.94,
P < 0.001), such that the association was strongest
among those older than 50 years (AOR = 1.75, 95%
CI = 1.38–2.22), those who were widowed/divorced/sepa-
rated (AOR = 1.22, 95% CI = 1.05–1.43) followed by those
who were married (AOR = 1.19, 95% CI = 1.07–1.32),
those who reported a family income greater than
$75,000 (AOR = 1.19, 95% CI = 1.08–1.31), non-
Hispanic White individuals (AOR = 1.19, 95% CI = 1.08–
1.30) and those with a college degree or higher
(AOR = 1.42, 95% CI = 1.23–1.65). The association be-
tween RML and past-month cannabis use significantly var-
ied by age (F(3) = 3.92, P = 0.008), such that the strongest

© 2021 Society for the Study of Addiction Addiction, 116, 2770–2778

2774 Renee D. Goodwin et al.

Table 1 (b) Prevalence of past-month daily cannabis use among adults with children <18 years in the household by cannabis legalization
status and sociodemographic characteristics, NSDUH 2017.

Cannabis legalization status

a a a
No MML (n = 7500) MML (n = 10,800) RML (n = 3900)

Overall 200 (2.35%) 500 (3.22%) 200 (4.21%)

Age
18–25 100 (4.81%) 200 (6.69%) 100 (8.26%)
26–34 <100 (3.21%) 100 (4.79%) <100 (6.10%)
35–49 <100 (1.55%) 100 (2.27%) <100 (3.60%)
≥50 <100 (1.02%) <100 (0.99%) <100 (0.39%)
Gender
Male 100 (3.07%) 300 (4.40%) 100 (5.47%)
Female <100 (1.77%) 200 (2.25%) 105 (3.19%)
Marital status
Married <100 (1.15%) 100 (1.80%) <100 (2.93%)
Widowed/divorced/separated <100 (3.35%) <100 (1.99%) <100 (2.24%)
Never married 100 (4.97%) 300 (6.86%) 100 (8.32%)
Income
<$20,000 <100 (3.63%) 100 (5.43%) <100 (7.20%)
$20,000–$74,000 <100 (2.80%) 200 (4.11%) <100 (4.82%)
≥$75,000 <100 (1.81%) 200 (2.29%) 100 (3.36%)
Race/Ethnicity
Non-Hispanic White 100 (2.26%) 300 (3.38%) 100 (5.13%)
Non-Hispanic Black <100 (3.41%) <100 (4.36%) <100 (7.35%)
Hispanic <100 (1.63%) <100 (2.39%) <100 (3.35%)
Non-Hispanic Other <100 (2.61%) <100 (1.90%) <100 (2.62%)
Education
Less than high school <100 (2.97%) <100 (4.74%) <100 (4.87%)
High school or equivalent <100 (3.28%) 200 (4.29%) <100 (5.89%)
Some college <100 (2.84%) 200 (3.98%) <100 (5.22%)
College graduate or above <100 (0.72%) <100 (1.01%) <100 (2.02%)

a
MML = medical marijuana laws; NSDUH = National Survey on Drug Use and Health; RML = recreational marijuana laws. Unweighted sample sizes must be
rounded to the nearest 100 to use NSDUH restricted-use data in the Research Data Center setting.

association was observed among those ages 26 to 34 DISCUSSION

(AOR = 1.40, 95% CI = 1.15–1.71).
Difference-in-difference estimates for past-month daily
cannabis use (Table 2b)
Similarly, both medical (AOR = 1.16, 95% CI = 1.02–1.32)
and recreational cannabis legalization (AOR = 1.25, 95%
CI = 1.03–1.51) were associated with increases in daily
cannabis use relative to states that did not have legalized
marijuana during the study period. For medical cannabis,
the association significantly varied by age (F(3) = 6.95,
P < 0.001), race/ethnicity (F(3) = 2.76, P = 0.041) and
education (F(3) = 5.71, P = 0.001), such that the strongest
associations were observed for those older than 50 years
(AOR = 2.09, 95% CI = 1.36–3.24), non-Hispanic White
individuals (AOR = 1.24, 95% CI = 1.07–1.44) and those
with a college degree or higher (AOR = 1.81, 95%
CI = 1.35–2.44). For RML, the association did not differ
by any sociodemographic subgroup.
The present study has three main findings. First, the odds
of cannabis use among adults with children in the home
are higher in states with RML, followed by MML, and low-
est in states without MML or RML. Second, RML adoption
appears to increase the odds of past-30-day cannabis use
and daily cannabis use among adults with children in the
home broadly across nearly all sociodemographic groups.
Third, MML adoption is associated with increased odds of
past-30-day cannabis use and daily cannabis use among
adults who are older, have higher incomes, and have
higher formal educational attainment.
Overall, MML and RML are associated with an increase
in cannabis use among adults with children living in the
home. This is consistent with previous findings reporting
associations between MML and increased cannabis use
outcomes in US adults overall and within certain age cate-
gories (e.g. ages 26+) [9,10,18,19]. In 2017, the preva-
lence of cannabis use among adults living with children

© 2021 Society for the Study of Addiction Addiction, 116, 2770–2778

 Cannabis use in adults with children at home 2775

Table 2 (a) Difference-in-difference estimates for past-month cannabis use among adults with children <18 years in the household,
NSDUH 2004–2017.

Adjusted DiD estimate

MML (AOR) 95% CI P_int RML (AOR) 95% CI P_int

Overall 1.12 (1.03, 1.22) 1.28 (1.12, 1.46)

Age
18–25 1.01 (0.92, 1.10) <0.001 1.01 (0.85, 1.20) 0.425
26–34 1.06 (0.95, 1.19) <0.001 1.40 (1.15, 1.71) 0.563
35–49 1.14 (1.03, 1.27) 0.001 1.39 (1.14, 1.70) 0.579
≥50 1.75 (1.38, 2.22) ref 1.22 (0.80, 1.87) ref
F(3) = 8.432, P < 0.001 F(3) = 3.919, P = 0.008
Gender
Male 1.09 (0.99, 1.19) 0.099 1.21 (1.02, 1.43) 0.214
Female 1.17 (1.06, 1.28) ref 1.37 (1.17, 1.60) ref
F(1) = 2.718, P = 0.099 F(1) = 1.547, P = 0.214
Marital status
Married 1.19 (1.07, 1.32) 0.010 1.46 (1.23, 1.74) 0.043
Widowed/divorced/separated 1.22 (1.05, 1.43) 0.041 1.05 (0.76, 1.45) 0.584
Never married 1.05 (0.96, 1.14) ref 1.16 (0.97, 1.38) ref
F(2) = 4.620, P = 0.010 F(2) = 2.895, P = 0.055
Income
<$20,000 1.07 (0.96, 1.20) 0.080 1.40 (1.08, 1.82) 0.334
$20,000–$74,999 1.04 (0.94, 1.16) 0.015 1.31 (1.06, 1.62) 0.585
≥$75,000 1.19 (1.08, 1.31) ref 1.21 (1.02, 1.45) ref
F(2) = 3.227, P = 0.040 F(2) = 0.490, P = 0.613
Race/Ethnicity
Non-Hispanic White 1.19 (1.08, 1.30) ref 1.23 (1.05, 1.44) ref
Non-Hispanic Black 1.14 (1.01, 1.39) 0.584 1.40 (1.00, 1.96) 0.467
Hispanic 0.89 (0.77, 1.03) <0.001 1.33 (1.06, 1.67) 0.580
Non-Hispanic Other 0.87 (0.72, 1.06) 0.001 1.48 (1.08, 2.02) 0.255
F(3) = 7.851, P < 0.001 F(3) = 0.552, P = 0.647
Education
Less than high school 0.88 (0.78, 0.99) <0.001 1.34 (1.01, 1.78) 0.599
High school or equivalent 1.12 (1.01, 1.24) 0.001 1.04 (0.80, 1.30) 0.035
Some college 1.12 (1.01, 1.24) 0.002 1.26 (1.04, 1.53) 0.322
College graduate or above 1.42 (1.23, 1.65) ref 1.47 (1.15, 1.89) ref
F(3) = 11.937, P < 0.001 F(3) = 1.646, P = 0.177

AOR = adjusted odds ratio; CI = confidence interval; DiD = difference-in-difference; MML = medical marijuana laws; NSDUH = National Survey on Drug Use
and Health; P_int = P value for interaction; RML = recreational marijuana laws. Adjusted ORs are from logistic regression models containing state and year
fixed effects, MML/RML, the sociodemographic factor of interest and their interactions, while simultaneously controlling for all other sociodemographic factors
in the table. The comparison group for all estimates are states that did not enact marijuana laws during the study period; P_int indicates a statistically signif-
icant difference.

in states with RML was higher than the prevalence among
the general adult population across the US [20].
The impact of legalization on cannabis use among
adults with children living in the home varied by
sociodemographic characteristics in several respects. Nota-
bly, RML had a more uniform impact on adults with chil-
dren living in the household, whereas MML had a
heterogeneous impact across certain groups including
age, income, and education. Our results suggest that
MML-associated increased use was particularly salient
among adults over the age of 50, both married or
widowed/divorced/separated and among those with
higher income and educational attainment. In contrast,
RML increased use broadly among adults across
sociodemographic groups. As states shift toward legalizing
cannabis for recreational use, a major public health prior-
ity should be to ensure that all adults, especially those in
vulnerable groups, have access and exposure to education
and treatment regarding the potential risks associated with
youth exposure to parental cannabis use.
Although much of the tobacco control and harm re-
duction efforts protecting youth from exposure to SHS
has focused on cigarette smoking outside/not in the pres-
ence of children, the potential risks of exposure to SCS
and education on the merits of protecting youth from expo-
sure to SCS have received little attention in the cannabis

© 2021 Society for the Study of Addiction Addiction, 116, 2770–2778

2776 Renee D. Goodwin et al.

Table 2 (b) Difference-in-difference estimates for past-month daily cannabis use among adults with children <18 years in the household,
NSDUH 2004–2017.

Adjusted DiD estimate

MML (AOR) 95% CI P_int RML (AOR) 95% CI P_int

Overall 1.16 (1.02, 1.32) 1.25 (1.03, 1.51)

Age
18–25 0.97 (0.84, 1.11) <0.001 1.06 (0.82, 1.39) 0.633
26–34 1.14 (0.96, 1.36) 0.007 1.38 (1.04, 1.82) 0.278
35–49 1.27 (1.06, 1.53) 0.028 1.41 (1.03, 1.92) 0.222
≥50 2.09 (1.36, 3.23) ref 0.88 (0.41, 1.86) ref
F(3) = 6.953, P < 0.001 F(3) = 1.326, P = 0.264
Gender
Male 1.13 (0.99, 1.30) 0.404 1.13 (0.89, 1.42) 0.083
Female 1.21 (1.02, 1.42) ref 1.46 (1.13, 1.89) ref
F(3) = 6.953, P < 0.001 F(3) = 1.326, P = 0.264
Marital status
Married 1.25 (1.05, 1.49) 0.075 1.54 (1.18, 2.02) 0.019
Widowed/divorced/separated 1.31 (0.99, 1.74) 0.175 1.10 (0.67, 1.80) 0.88
Never married 1.08 (0.94, 1.24) ref 1.06 (0.83, 1.35) ref
F(2) = 2.237, P = 0.107 F(2) = 2.895, P = 0.055
Income
<$20,000 1.15 (0.96, 1.38) 0.605 1.40 (1.00, 1.96) 0.544
$20,000–$74,999 1.10 (0.93, 1.30) 0.286 1.16 (0.87, 1.54) 0.668
≥$75,000 1.21 (1.03, 1.42) ref 1.25 (0.96, 1.61) ref
F(2) = 0.570, P = 0.565 F(2) = 0.408, P = 0.665
Race/Ethnicity
Non-Hispanic White 1.24 (1.07, 1.44) ref 1.18 (0.94, 1.48) ref
Non-Hispanic Black 1.08 (0.89, 1.33) 0.197 1.47 (0.88, 2.44) 0.416
Hispanic 1.04 (0.81, 1.32) 0.137 1.31 (0.92, 1.86) 0.586
Non-Hispanic Other 0.81 (0.58, 1.13) 0.009 1.45 (0.90, 2.35) 0.424
F(3) = 2.764, P = 0.041 F(3) = 0.412, P = 0.744
Education
Less than high school 0.98 (0.82, 1.18) <0.001 1.33 (0.95, 1.88) 0.942
High school or equivalent 1.08 (0.92, 1.27) 0.001 1.09 (0.81, 1.47) 0.482
Some college 1.22 (1.03, 1.45) 0.013 1.26 (0.96, 1.66) 0.928
College graduate or above 1.81 (1.35, 2.44) ref 1.30 (0.83, 2.04) ref
F(3) = 5.711, P = 0.001 F(3) = 0.380, P = 0.767

AOR = adjusted odds ratio; CI = confidence interval; DiD = difference-in-difference; MML = medical marijuana laws; NSDUH = National Survey on Drug Use
and Health; P_int: P value for interaction; RML = recreational marijuana laws. Adjusted ORs are from logistic regression models containing state and year
fixed effects, MML/RML, the sociodemographic factor of interest and their interactions, while simultaneously controlling for all other sociodemographic factors
in the table. The comparison group for all estimates are states that did not enact marijuana laws during the study period; P_int indicates a statistically signif-
icant difference.

legalization effort. Specifically, it is not clear to what degree
analogous approaches are being taken to prevent SCS ex-
posure in children.
In contrast to cigarettes, there are no public health or
clinical guidelines for parents designed to address or edu-
cate about best practices for use of cannabis toward
avoiding or reducing harmful exposures of SCS to chil-
dren’s health. Furthermore, because cannabis is legal for
use only in private dwellings in most states with RML, pro-
grams that advocate using combustible products outside
and keeping a “smoke-free home” are not a viable solution
for reducing SCS. Given that SCS exposure has a number of
undesirable health risks for youth, and adolescents with
parents who use cannabis are at increased risk of cannabis
use themselves [16], estimating the degree to which can-
nabis use has increased among adults with children in
the home, whether the distribution of cannabis use differs
among vulnerable sociodemographic groups, and whether
legalization of cannabis for recreational and/or medical use
has impacted changes in cannabis use are critical to inform
the allocation of resources for prevention and intervention
efforts to protect children in this new era of increasing can-
nabis laws.
Limitations must be considered in interpreting these re-
sults. First, social desirability may differentially affect re-
sponses in states based on legalization, thereby leading to

© 2021 Society for the Study of Addiction Addiction, 116, 2770–2778


higher reporting of cannabis use in states where cannabis
is legal and artificially suppressing reports of use in states
where cannabis remains illegal. Second, the DiD estimates
assume that there are no unmeasured factors that differen-
tially affected cannabis use outcomes in states that enacted
MML/RML during the study period versus comparison
states. Nonetheless, the higher cross-sectional prevalence
of use among adults with children in the home in states
with these laws suggests that state marijuana legalization
status is an important indicator of potential youth SCS ex-
posure. Third, it is difficult to draw conclusions about the
impact of cannabis use on children’s health because this
outcome is not one of the outcomes of the current study
and there are no data on age of the children, which means
that it is not possible to examine the nature of potential im-
pact and level of exposure. Next steps in this line of research
should focus on examining these outcomes, especially
among children who are physically vulnerable (e.g. infants,
children with respiratory conditions like asthma) to SCS
exposure.
The current data are also unable to address
completely the degree to which cannabis use among
adults affects children’s exposure to SCS in the home for
at least two reasons: we do not have information on loca-
tion of smoking, whether it occurs in the house and/or in
the proximity of children; and we do not have informa-
tion about the quantity of use because even daily canna-
bis use is likely to produce a different quantity than
non-daily use. Further, we do not have information about
the methods of cannabis use among parents, which
would affect the level of possible SCS exposure. Recent ev-
idence indicates most cannabis use occurs via smoking
whereas edible forms account for less than 10% of use
among US adults [21,22]. Future research is needed to
obtain specific estimates of the degree to which dose
and length of exposure are changing among children in
the home. Furthermore, exposure of children to SCS at
a certain age could be more detrimental than at other
ages because of the “critical period” effect, but the
NSDUH does not specify age of children in the household.
Research using biomarkers of cannabis and tobacco expo-
sure in children of different ages and in households
implementing varying degrees of protection (e.g. house-
hold smoking bans) is warranted to advance the field.
Our findings suggest that both MML and RML are as-
sociated with increases in cannabis use among adults
with children in the home. We found that RML have a
broader impact whereas MML are associated with in-
creases among adults who are older, with higher educa-
tion, and income levels. As an increasing number of
states legalize cannabis for medical or recreational use,
educational efforts to prevent unintended consequences
in terms of risks to children via exposure to parental can-
nabis use may be essential.
© 2021 Society for the Study of Addiction
Cannabis use in adults with children at home 2777
Declaration of interests
None.
Acknowledgements
This work was supported by the National Institutes of
Health/National Heart, Lung and Blood Institute grant
R21-HL149773 and the National Institute on Drug Abuse
grant R01-DA20892 to Goodwin. The National Institutes
of Health had no further role in study design; in the collec-
tion, analysis, and interpretation of data; in the writing of
the report; or in the decision to submit the paper for
publication.
Author contributions
Renee Goodwin: Conceptualization; funding acquisition;
investigation; methodology. June Kim: Formal analysis; in-
vestigation. Keely Cheslack-Postava: Investigation; meth-
odology. Andrea Weinberger: Investigation. Melody Wu:
Investigation. Katarzyna Wyka: Investigation; methodol-
ogy. Meyer Kattan: Investigation; methodology.
References
1. King K., Martynenko M., Bergman M., Liu Y., Winickoff J.,
Weitzman M. Family composition and children’s exposure to
adult smokers in their homes. Pediatrics 2009; 123:
e559–e564.
2. Dwyer T., Ponsonby A. L., Couper D. Tobacco smoke exposure
at one month of age and subsequent risk of SIDS--a prospec-
tive study. Am J Epidemiol 1999; 149: 593–602.
3. Matt G. E., Quintana P. J., Hovell M. F., Bernert J. T., Song S.,
Novianti N., et al. Households contaminated by environmen-
tal tobacco smoke: sources of infant exposures. Tob Control
2004; 13: 29–37.
4. U.S. Department of Health and Human Services. Surgeon Gen-
eral’s Report—The Health Consequences of Involuntary Exposure
to Tobacco Smoke. Atlanta, GA: U.S. Department of Health
and Human Services, Centers for Disease Control and Preven-
tion, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health; 2006.
5. Collins B. N., Nair U. S., Hovell M. F., DiSantis K. I., Jaffe K.,
Tolley N. M., et al. Reducing underserved children’s exposure
to tobacco smoke: a randomized counseling trial with mater-
nal smokers. Am J Prev Med 2015; 49: 534–44.
6. Levy D., Chaloupka F., Gitchell J. The effects of tobacco control
policies on smoking rates. J Public Health Manag Pract 2004;
10: 338–53.
7. Hasin D. S., Saha T. D., Kerridge B. T., Goldstein R. B., Chou
S. P., Zhang H., et al. Prevalence of marijuana use disorders
in the United States between 2001-2002 and 2012-2013.
JAMA Psychiat 2015; 72: 1235–42.
8. Compton W. M., Han B., Jones C. M., Blanco C., Hughes A.
Marijuana use and use disorders in adults in the USA,
2002-14: analysis of annual cross-sectional surveys. Lancet
Psychiatry 2016; 3: 954–64.
9. Goodwin R. D., Pacek L. R., Copeland J., Moeller S. J., Dierker
L., Weinberger A., et al. Trends in daily cannabis use among
cigarette smokers: United States, 2002-2014. Am J Public
Health 2018; 108: 137–42.
Addiction, 116, 2770–2778
2778 Renee D. Goodwin et al.
10. Hasin D., Sarvet A., Cerdá M., Keyes K., Stohl M., Galea S.,
et al. US adult illicit cannabis use, cannabis use disorder, and
medical marijuana laws. JAMA Psychiat 2017; 74: 579–88.
11. Rusby J., Westling E., Crowley R., Light J. Legalization of recre-
ational marijuana and community sales policy in Oregon:
impact on adolescent willingness and intent to use, parent
use, and adolescent use. Psychol Addict Behav 2018; 32:
84–92.
12. Volkow N. D., Baler R. D., Compton W. M., Weiss S. R. Adverse
health effects of marijuana use. N Engl J Med 2014; 370:
2219–27.
13. Volkow N. D., Swanson J. M., Evins A. E., DeLisi L. E., Meier
M. H., Gonzalez R., et al. Effects of cannabis use on human be-
havior, including cognition, motivation, and psychosis: a
review. JAMA Psychiat 2016; 73: 292–7.
14. Pacek L. R., Mauro P. M., Martins S. S. Perceived risk of regular
cannabis use in the United States from 2002 to 2012: differ-
ences by sex, age, and race/ethnicity. Drug Alcohol Depend
2015; 149: 232–44.
15. Pacek L. R., Weinberger A. H., Zhu J., Goodwin R. D. Rapid in-
crease in the prevalence of cannabis use among people with
depression in the United States, 2005–17: the role of
differentially changing risk perceptions. Addiction 2019 Epub
ahead of print.
16. Madras B. K., Han B., Compton W. M., Jones C. M., Lopez E. I.,
McCance-Katz. Associations of parental marijuana use with
offspring marijuana, tobacco, and alcohol use and opioid mis-
use. JAMA Netw Open 2019; 2: e1916015.
17. Williams A. R., Olfson M., Kim J. H., Martins S. S., Kleber H. D.
Older, less regulated medical marijuana programs have much
greater enrollment rates than newer ‘medicalized’ programs.
Health Aff (Millwood) 2016; 35: 480–8.
18. Martins S. S., Mauro C. M., Santaella-Tenorio J., Kim J. H.,
Cerda M., Keyes K. M., et al. State-level medical marijuana
laws, marijuana use and perceived availability of marijuana
among the general U.S. population. Drug Alcohol Depend
2016; 169: 26–32.
© 2021 Society for the Study of Addiction
19. Cerda M., Mauro C., Hamilton A., Levy N. S., Santaella-
Tenorio J., Hasin D., et al. Association between recreational
marijuana legalization in the United States and changes in
marijuana use and cannabis use disorder from 2008 to
2016. JAMA Psychiat 2019.
20. Weinberger A. H., Zhu J., Levin J., Barrington-Trimis J. L.,
Copeland J., Wyka K., et al. Cannabis use among US adults
with anxiety from 2008 to 2017: the role of state-level can-
nabis legalization. Drug Alcohol Depend 2020; 214: 108163.
21. Schauer G. L., King B. A., Bunnell R. E., Promoff G., McAfee
T. A. Toking, vaping, and eating for health or fun: mari-
juana use patterns in adults, U.S., 2014. Am J Prev Med
2016; 50: 1–8.
22. Borodovsky J. T., Crosier B. S., Lee D. C., Sargent J. D., Budney
A. J. Smoking, vaping, eating: is legalization impacting the
way people use cannabis? Int J Drug Policy 2016; 36: 141–7.
Supporting Information
Additional supporting information may be found online in
the Supporting Information section at the end of the
article.
Figure S1 (a) Trends in the prevalence of past-month can-
nabis use among adults with children living in the house-
hold, 2004–2013 National Survey on Drug Use and
Health. (b) Trends in the prevalence of past-month daily
cannabis use among adults with children living in the
household, 2004–2013 National Survey on Drug Use
and Health.
Addiction, 116, 2770–2778
This document is a scanned copy of a printed document. No warranty is given about the
accuracy of the copy. Users should refer to the original published version of the material.