Relative Preference of Cannabis, Alcohol, and Nicotine Products Among U.S. Adolescents and Young Adults Who Are Using or Susceptible to Cannabis Use: Insights from a Best-Worst Scaling Study

Abstract

Background: The prevalence of multiple substance use is high among U.S. adolescents and young adults (AYAs), particularly as market shifts with alcohol and cannabis being the most prevalent substances and nicotine vaping displacing cigarette smoking among this population. However, it remains unclear how AYAs evaluate diverse products in terms of preference, addictiveness, and risk. Methods: We analyzed data from a nationally representative sample of 1,010 U.S. AYAs (aged 15–21) in June 2024 who had used cannabis in the past 30 days or were susceptible to use. Best-worst scaling (BWS) was used to elicit relative preferences across alcohol, tobacco, and cannabis forms. Product-level indices for liking, addictiveness, and risk were analyzed using fractional logistic regression. Results: Cannabis edibles, alcohol, and cannabis flower ranked highest in liking, while tobacco products—especially cigarettes—were less preferred. E-cigarettes and oral nicotine pouches were more favored than cigarettes but remained less liked than cannabis products. Among cannabis forms, cartridges were perceived as both the most addictive and risky, whereas topicals were viewed as least harmful. Regression results showed cannabis oil and most tobacco products were less liked than flowers, while topicals were perceived as less addictive and risky than flowers. Conclusions: AYAs favor cannabis edibles and alcohol while disfavoring traditional tobacco products. Perceptions of risk and addictiveness align with product delivery modes, particularly for high-THC vaping products. These findings suggest both substitution (e.g., away from cigarettes) and complementarity (e.g., cannabis and alcohol), underscoring the need for integrated, multi-product regulatory strategies targeting evolving substance markets.