In the United States, over 1 in 5 high school students report that they currently drink alcohol, and over 1 in 6 report they currently use cannabis [1]. While more research is needed to better understand the health effects of cannabis use, there are known health consequences of cannabis use among youth. For instance, regular and frequent cannabis use during adolescence is associated with impairments in learning, memory, and attention, especially as the brain continues to develop until age 25 [2, 3, 4, 5, 6, 7, 8]. Previous research has identified a strong relationship between daily cannabis use before age 17 and lower rates of high school graduation, risk for cannabis dependence, developing cannabis use disorder, use of other illicit drugs, and suicidal behaviors [2, 9, 10, 11]. Over the past decades, the perceived risk of regular cannabis use has decreased among adolescents [8, 12]. However, between 2022 and 2023 perceived risk of harm of regular cannabis use increased among 8th graders (53.6–54.4%), 10 th graders (42.2–47.0%), and 12th graders (27.6–31.4%) [13–15]. Despite this positive trend in perceived risk of harm of regular cannabis use by youth, there is still a need for focused and effective interventions to protect American youth from cannabis-associated harms.

The cannabis landscape across the United States is rapidly changing. In 2000, eight states allowed medical cannabis use and no states permitted non-medical adult cannabis use [16]. As of January 2025, 24 states, two territories, and the District of Columbia allow non-medical adult cannabis use, and 39 states, three territories, and the District of Columbia allow medical cannabis use [16]. While non-medical cannabis use remains illegal for all persons under 21 years of age in the United States, non-medical adult use legalization in Canada has been associated with easier access to cannabis [17]. Previous research has found exposing adolescents to cannabis marketing, whether through social media platforms or billboards, increases their odds of past-year cannabis use, weekly cannabis use, and cannabis use disorder [18, 19]. In addition to policy changes over the past two decades, cannabis products and routes of administration are evolving. For example, the concentration of tetrahydrocannabinol (THC), which is the main psychoactive cannabinoid in most cannabis products, has been increasing over time [20, 8]. Some modes of use (e.g., dabbing) facilitate the use of highly concentrated THC products, and youth who use highly concentrated products are at an increased risk of developing cannabis use disorder [21].

Together, the issues of expanded legalization, the related potential for increased access to cannabis among youth, and the well-known deleterious effects of cannabis use during youth and adolescence underline the need for focused cannabis prevention efforts among youth. Such efforts have begun to be implemented in communities across the United States, but to our knowledge, no formal review of such commonly implemented programs and practices exists. An assessment of these efforts and, particularly the extent to which evidence-based prevention efforts are being implemented in communities addressing these issues, could help inform future prevention activities, reduce the potential harmful effects of legalization, and shape substance use behaviors among youth and adolescents.

The Drug-Free Communities (DFC) Support Program is the nation’s leading effort to mobilize communities to prevent youth substance use [22]. The DFC program provides up to $125,000 annually to community coalitions to strengthen the infrastructure among local partners to create and sustain a reduction in youth substance use. DFC recipients can receive up to five years of funding per award, for a maximum of ten years. In 2024, the White House’s Office of National Drug Control Policy (ONDCP), which administers the DFC program, funded over 750 coalitions across all 50 states, Puerto Rico, Guam, and the US Virgin Islands.

The bedrock of DFC is the community-based coalition, which is made up of 12 required sectors (e.g., parents, businesses, law enforcement; Fig. 1) that work collectively to build capacity to reduce youth substance use. DFC continues to expand their reach to communities across the county, as of 2022 approximately 20% of Americans lived in communities with a DFC-funded coalition and in the 2024 fiscal year over 750 DFC coalitions received funding [23]. Coalitions are required to recruit members from the 12 sectors to design an approach, leverage existing services, and implement a comprehensive strategy with the goal of youth substance use prevention. Coalitions are required to direct prevention activities toward at least two substances (e.g., alcohol and cannabis) and develop an annual action plan describing planned programmatic activities for the budget period that align with the two DFC goals: (1) building capacity, and (2) reducing youth substance use.

The “Seven Strategies for Community Change,” (henceforth referred to as the Seven Strategies), provide a framework for a comprehensive, community-wide approach for preventing youth substance use at the community level (Table 1). The Seven Strategies include: (1) providing information, (2) enhancing skills, (3) providing support, (4) enhancing access and reducing barriers, (5) changing consequences, (6) physical design, and (7) educating/informing about policy [24]. Providing information, enhancing skills, and providing support focus on individuals and small groups. These strategies often rely on person-to-person interactions and may not have broad reach. Enhancing access and reducing barriers, changing consequences, physical design, and educating/informing about policy reinforces the first three strategies and creates a comprehensive community-level approach to youth substance use prevention. The strategies and activities coalitions choose to implement are selected and tailored to the needs and attributes of the community.

Promising activities to prevent youth initiation of cannabis use are needed at the community level. DFC coalitions have implemented comprehensive plans and activities, such as raising awareness, training, policy, and community-wide strategies, to address youth cannabis use and identify problems in their communities. This study reviewed the programmatic activities implemented by DFC coalitions to prevent youth cannabis use and assessed whether activities align with the Seven Strategies.

At the time of this review, DFC coalitions were required to submit biannual progress reports (PR) including strategy sections representing each of the Seven Strategies. Coalitions can report on multiple programmatic activities within each of the strategy sections.

Since coalitions reported on multiple programmatic activities in their PRs, the coalitions’ submissions were analyzed at the activity level. For cannabis-related programmatic activities to be included within the dataset, the coalitions had to explicitly state they were targeting cannabis, marijuana, cannabidiol (CBD), or tetrahydrocannabinol (THC) in their activities. If the coalitions mentioned they were targeting cannabis, marijuana, CBD, or THC, then these activities were considered “cannabis-related.” Activities recording no progress during the reporting period, August 2020 to February 2021, or those that were not related to cannabis, marijuana, CBD, or THC were removed from the dataset. Five study team members independently reviewed cannabis-related programmatic activities initially identified from each PR section to prescribe one to three keywords or phrases that could describe each. Examples of keywords or phrases used during this process were “education,” “community events,” “neighborhood safety,” and “awareness about local policies.” The study team collectively reviewed the keywords and assigned themes based on the keywords. Lastly, each PR section was analyzed to identify the most and least common themes. During the review process, salient and successfully implemented programmatic activities were flagged (Table 2). Indicators of success reported by the recipients included large community turnout at events, knowledge gained from training, and engagement with social media messaging and ads. The study team determined that the most infrequently reported themes across all activities were areas where coalitions and local organizations could improve their cannabis-related prevention efforts. The miscellaneous theme served as a catch-all for activities that did not clearly fit within another identified theme.

When reviewing cannabis-related activities by how coalitions reported them in accordance with the Seven Strategies, they were distributed as follows: providing information (n= 135; 27.7%), educating/informing about policy (n= 127; 26.0%), enhancing skills (n= 70; 14.3%), physical design (n= 48; 9.8%), change consequences (n= 40; 8.2%), reducing access and enhancing barriers (n= 35; 7.2%), and providing support (n= 33; 6.8%) (Table 1).

The most common themes identified across reported cannabis-related activities were dissemination, followed by training and education, policy and enforcement, community partnerships, miscellaneous, and communities of focus. The least commonly identified theme was communities of focus. When coalitions did report cannabis-related programmatic activities within this theme, examples of activities included: providing resources and information to families in need and providing linkage to care to treatment services and community resources, if needed. The theme was communities of focus which aligns with the Providing Support Seven Strategies category, which focuses on offering opportunities to reduce substance use risk and enhance protection, and was also the least commonly reported strategy category.

An example of enhancing protection in communities to reduce substance use risk would be limiting the number of cannabis advertisements in the community. Populations have been disproportionally affected by cannabis use due to dispensary locations that have placed certain groups at increased risk for exposure to cannabis advertisements [26]. These groups report higher exposure rates to cannabis dispensary advertisements, compared to their counterparts [26]. One proposal to address cannabis advertising exposure is to restrict cannabis dispensary’s online and billboard advertisements to locations where no more than 30% of the target audience is under the age of 21 (known as the 70/30 rule). In addition to the 70/30 rule, other policy proposals include restrictions on advertisements that target youth by prohibiting the use of toys, cartoon characters, and other elements designed to appeal to younger audiences [26].

Strengths among cannabis-related programmatic activities, which were the most frequently identified themes, included dissemination, training and education, policy and enforcement, and community partnerships. The theme of dissemination directly maps onto the Providing Information Seven Strategies category. Providing information ranges from hosting educational workshops, distributing data, or developing mass media campaigns [24]. Due to the COVID-19 pandemic and social distancing requirements, coalitions had to establish unique ways to disseminate information materials to their communities. Providing information was one of the Seven Strategies that could be adapted and continued in the virtual environment. Creating online materials and disseminating information via websites and social media channels was a common practice of organizations during the pandemic [27]. Many public health organizations relied on social media to bring awareness to public health protections against COVID-19 [28]. Coalitions used social media to increase health promotion and bring awareness to their communities on topics related to youth substance use. Creating virtual videos, social media posts about substance use and coping skills, expanding messaging across various social media platforms, and continually updating their websites were all ways coalitions tackled adapting to the changing environment and continued implementing activities. Establishing unique ways to provide information helped coalitions stay connected and keep their communities informed.

Another strength identified was training and education, which was 30% (n= 147) of reported cannabis-related activities. Training and education directly align with the Enhancing Skills Seven Strategies category. Surveys and knowledge assessments were incorporated into training sessions to assess the information retained by participants and identify aspects considered the strengths of the training as well as needed areas for improvement. Coalitions incorporated workshops focused on educating youth about substance use prevention, communication skills, and team-building exercises with aims for youth to make informed decisions around substance use and share accurate information with their peers. These workshops are similar to competence-enhancement programs that focus on teaching youth problem-solving skills, coping strategies, and social skills that equip youth with skills to navigate challenges in their everyday life, but also in situations related to substance use [29]. Other ways coalitions aligned their activities with the enhancing skills Seven Strategies category were by hosting virtual webinars discussing harms of cannabis use and its effects on the developing brain, creating online trainings accessible on their websites, and hosting forums to update the community on legalization of non-medical cannabis use in their state.

Policy and enforcement was another strength identified across cannabis-related programmatic activities. The identified policy and enforcement theme directly aligned with the Educating/Informing about Policy Seven Strategies category. Coalitions highlight policies that provided individuals access to substance use services if they were found to be vaping or smoking cannabis on school grounds. Comprehensive school tobacco use policies have been found to have an effect on student’s smoking behaviors, such as reducing their odds of smoking initiation [30]. A comprehensive school tobacco policy has been previously defined by inclusion of the following components: (1) restricting the use of substances on school grounds; (2) restricting the use of substances near school grounds; (3) students are not allowed to leave schools grounds throughout the day; and (4) incorporating prevention education programs [31, 32]. These policies decrease the punitive nature of a first offense and provide youth with access to resources and services to improve their health. Another way coalitions increased access to resources and intervention services was by enrolling youth with a first-offense cannabis charge into intervention programs for cannabis. These intervention programs were offered as an alternative disciplinary action to receiving out-school suspension.

An additional strength identified was community partnerships, which included activities like providing youth with alternative options in their community through drug-free social events (e.g., school-wide events like awareness weeks and conducting community-wide environmental scans). Conducting community-wide environmental scans directly aligns with the Physical Design Seven Strategies category. Coalitions reported conducting surveillance on substance use/retail locations. Retail dispensary density scans have been used to identify where cannabis dispensaries are in comparison to schools, common walking paths of youth and populations are at increased risk of substance use. Coalitions not only assessed dispensary proximity to schools, but also unlicensed dispensaries in the area and assessment of products sold from dispensaries in the area.