Cannabis use is on the rise across the United States, with 38 states legalizing medical cannabis use and 23 states legalizing recreational use as of June 2024 (National Conference of State Legislatures, 2024). Public acceptance of cannabis has also increased significantly, with about 68 % of Americans supporting legalization (Pew Research Center, 2021). Cannabis use in the United States is prevalent, with various patterns of use observed across the population. Approximately 16.0 % of U.S. adults report using cannabis recreationally on an annual basis, while about 9.0 % use it for medical purposes (Boehnke et al., 2019, SAMHSA, 2022). A substantial majority of individuals who use cannabis for medical purposes also report concurrent recreational use, whereas exclusive medical use is comparatively less common (Boehnke et al., 2019, Schauer et al., 2016, Turna et al., 2020). In terms of recent use, around 12.0 % of adults reported using cannabis in the past month, and 6.0 % reported daily use (SAMHSA, 2022) These statistics underscore the widespread nature of cannabis consumption and highlight the importance of understanding its implications for public health.

From 2002–2022, past-month prevalence of cannabis use increased from 6.2 % to 12.0 %, while daily or almost daily use increased from 1.9 % to 6.0 % among U.S. adults (SAMHSA, 2022). Recent analyses document particularly dramatic increases in daily use. Caulkins (2024) reports a 15-fold increase in the per capita rate of cannabis use between 1992 and 2022, highlighting a substantial shift in consumption patterns. Notably, in 1992, the number of people who consumed alcohol outnumbered those who used cannabis by a factor of 10 (8.9 million vs. 0.9 million). However, by 2022, this trend had reversed for the first time, with more individuals reporting cannabis use (17.7 million) compared to alcohol (14.7 million), signaling a fundamental change in substance use behaviors. Cannabis potency found in products on the market has also changed substantially, increasing from an average THC content of 4 % in the early 1990s to over 15 % in recent years (Chandra et al., 2019).

Despite increasing acceptance of cannabis legalization among Americans, there is a decreasing perception of cannabis use as risky, despite evidence linking it to numerous adverse outcomes, such as cognitive decline, psychosocial impairments, vehicle crashes, emergency department visits, psychiatric symptoms, poor quality of life, use of other drugs, cannabis withdrawal syndrome, and addiction risk (Volkow et al., 2014; Hall, 2014). The escalation of cannabis use is correlated with an increased risk of cannabis use disorder (CUD), affecting approximately 17 % of individuals who use cannabis (Hasin et al., 2015, Lapham et al., 2023, Dawson et al., 2024). CUD is broadly defined as the inability to stop consuming cannabis despite it causing physical or psychological harm (APA,2022).

Historically, it was estimated that approximately 1 in 10 individuals who had used cannabis would develop dependence, based on data from the National Comorbidity Survey (NCS) conducted in the early 1990s, which found a lifetime prevalence of cannabis dependence at 9.1 % among adults who had ever used cannabis (Anthony et al., 1994). This estimate likely underestimated the risk, as many early cannabis consumers had only experimented with the substance a few times (Caulkins, 2017). Additionally, cannabis products have become significantly more potent over the past few decades (Chandra et al., 2019) which is worrisome given that products with high-THC are known for their adverse effects related to increased risk of cannabis use disorder (CUD), cognitive impairment, and psychiatric symptoms, including anxiety, psychosis, and dependence (Freeman and Winstock, 2015, Volkow et al., 2014). Studies have shown that higher THC concentrations are associated with a greater likelihood of developing dependence and experiencing withdrawal symptoms (Connor et al., 2021). Furthermore, frequent use of high-potency cannabis has been linked to an elevated risk of psychotic disorders, particularly among individuals with a genetic predisposition or prior mental health conditions (Di Forti et al., 2019). As cannabis markets expand and products with increasingly high THC levels become more accessible, concerns regarding their long-term public health implications continue to grow.

Recent cohort studies and systematic reviews indicate higher prevalence rates of CUD among individuals who use cannabis more frequently . The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) in the USA reported a past-year prevalence of DSM-IV cannabis dependence of 7–8 % among adults who had used cannabis (Blanco et al., 2016, Lopez-Quintero et al., 2011; Boness et al., 2025).

One of the primary risk factors for developing CUD is frequency of cannabis use (Blanco et al., 2016). The prevalence of CUD is notably higher among those who use cannabis frequently, particularly those who use it daily . Despite the dramatic increase in past month and daily or almost daily cannabis use, the distribution of use frequency, and relationship to developing a CUD, have not been adequately described, particularly when differentiating between medical and non-medical cannabis use. It is crucial to distinguish between these two categories as the motivations, patterns of use, and potential risks, including the development of CUD, may differ significantly between individuals using cannabis for medical versusnon-medical reasons (Boehnke et al., 2019).

This study aims to evaluate whether the prevalence of CUD differs among individuals based on self-reported reasons for cannabis use across the U.S. while assessing the frequency of past-month cannabis use. Utilizing a nationally representative survey, we assessed the prevalence of CUD among individuals with past-month cannabis use, stratifying them into two categories based on self-reported reasons for use: medical use and nonmedical (recreational) use, while also assessing frequency of use. Our analysis seeks to elucidate potential variations in CUD risk associated with different patterns of cannabis use, providing valuable insights for public health interventions and policies aimed at mitigating adverse outcomes linked to cannabis use.