Racial and Ethnic Differences in Suicide Mortality Among Youth Aged 12-25 Years Following Medical and Recreational Cannabis Legalization in the U.S.

Abstract

Cannabis legalization has often been framed as social justice reform in the U.S., but it may have unintended downstream outcomes that vary by race and ethnicity. One such outcome is suicide, which is rising among U.S. youth and associated with cannabis use. This study examined associations between state medical and recreational cannabis law enactment and changes in suicide mortality by race and ethnicity among U.S. youth. Suicide deaths (N=113,512) from the 2000-2019 National Vital Statistics System death files for individuals aged 12-25 years were examined in relation to time-varying cannabis law status across racial and ethnic subgroups, using a staggered-adoption difference-in-difference approach that controlled for time-varying state- and individual-level covariates. National Vital Statistics System data were obtained in 2022. Analyses were conducted from June 2024 to July 2025. Unadjusted annual suicide rates were 9.7, 12.8, and 16.7 per 100,000 youth for no cannabis law, medical cannabis law, and recreational cannabis law states, respectively. Significant race/ethnicity-by-cannabis law effects were observed. Asian/Pacific Islander youth living in medical and recreational cannabis law states had increased incident rate ratios for suicide deaths compared with those of Asian/Pacific Islander youth living in no cannabis law states (medical cannabis law: increased incident rate ratio, 1.30; 95% CI=1.13, 1.50; recreational cannabis law: increased incident rate ratio, 1.42; 95% CI=1.20, 1.67). Hispanic youth living in recreational cannabis law states had increased suicide deaths when compared with Hispanic youth living in medical cannabis law states (increased incident rate ratio, 1.15; 95% CI=1.04, 1.27) and no cannabis law states (increased incident rate ratio, 1.32; 95% CI=1.03, 1.71). Cannabis law-related differences in suicides for American Indian/Alaska Native, non-Hispanic Black, and non-Hispanic White youth were nonsignificant. Findings were consistent across sensitivity analyses. Medical and recreational cannabis laws were associated with increased suicide deaths in Asian/Pacific Islander and Hispanic youth. Mechanisms through which cannabis laws differentially influence suicide mortality among youth of varied racial and ethnic backgrounds warrant further study and should inform legislative reform.