Might cannabis Legalization Have Affected Public Health-Relevant Alcohol- and Tobacco-use Outcomes in Canada?

Fischer B.; Hall W.; Jutras-Aswad D.; Le Foll B. · Nordisk alkohol- & narkotikatidskrift : NAT · 2026

**Background & Methods** This is a narrative review commentary examining Canada's cannabis legalization in 2018 and its potential public health impacts on alcohol and tobacco use outcomes in the general population. The authors synthesize existing literature on substitution and complementarity dynamics between cannabis and other substance use to identify gaps in current evidence. **Key Findings** - Cannabis legalization in Canada has produced mixed public health outcomes: documented decreases in cannabis-related crime and illegal market activity, but increases in multiple acute and chronic health problem indicators associated with cannabis use. - Existing literature suggests cannabis legalization may affect alcohol and tobacco use through both substitution effects (cannabis replacing other substances) and complementarity effects (cannabis use co-occurring with increased use of other substances), yet empirical evidence remains unclear regarding causal relationships. - Despite marked increases in cannabis use prevalence following legalization, recent epidemiological data show possible small changes in alcohol and tobacco use patterns, but the causal relationship between cannabis legalization and these shifts remains unestablished and requires rigorous analytical investigation. **Dosage & Administration** Not reported. **Safety & Adverse Effects** The review notes that cannabis legalization has been associated with increases in many acute and chronic health problems, though specific adverse effects are not detailed. The authors emphasize the substantial existing public health burden from alcohol and tobacco use in Canada, suggesting these substances remain significant health concerns that may be affected by cannabis policy changes. **Evidence Quality** This is a commentary/narrative review with inherent limitations. The authors identify a critical gap in the current literature: potential causal impacts of cannabis legalization on alcohol and tobacco use have not been adequately examined using rigorous analytical methods. The level of evidence is low, as the paper synthesizes existing literature rather than presenting original research data. The authors explicitly call for future systematic examination using rigorous analytical approaches to determine whether observed changes in alcohol and tobacco use are causally related to cannabis legalization. The review's value lies primarily in highlighting an understudied public health question relevant not only to Canada but also other jurisdictions with legalized cannabis.

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