Cancer survivors with more ACEs had higher odds of cannabis use, consistent with broader literature associating childhood adversity with adult substance use [6, 11]. Our findings contribute to previous research [1, 3, 6, 7] by extending this association to cancer survivors, who often experience additional psychological and physical challenges that may further contribute to cannabis use [8, 11]. Prior research has consistently shown that individuals reporting multiple ACEs have a significantly higher likelihood of engaging in substance use, including cannabis, to manage stress, anxiety, and unresolved psychological distress [6, 7]. The observed association between ACEs and cannabis use underscores the need for targeted interventions for cancer survivors with a high ACE burden, as well as the importance of evidence‐based guidelines for cannabis use in oncology. The prevalence of cannabis use among cancer survivors in our cohort was 6%, compared to estimates from the literature ranging from 8% to 31% [13, 14, 15]. The relatively low prevalence of cannabis use observed in our study may reflect limited legalization across participating states in 2020 and the lag between policy change and behavior [10, 16, 17].

We found that cancer survivors with a history of ≥ 4 ACEs had higher odds of reporting cannabis use. Research suggests that early‐life stress may shape neurobiological pathways involved in reward and stress regulation, which could influence substance use behaviors later in life [3, 18]. While cannabis use may provide symptomatic relief for cancer‐related issues [11], the elevated prevalence among those with high ACEs raises concerns about potential dependence. Cancer survivors with a history of ACEs may be at an increased risk of using cannabis not solely for medical purposes but also as a means of coping with underlying psychological distress. This raises important considerations for healthcare providers, as unregulated or excessive cannabis use may contribute to dependency, exacerbate mental health conditions, or interfere with cancer treatments [15]. Despite growing interest in cannabis as a therapeutic agent, clinical guidelines in oncology remain limited due to insufficient evidence on dosing, administration, and long‐term safety [11]. The American Society of Clinical Oncology recently published guidelines cautioning that while cannabis can be beneficial for certain symptoms, its use should be carefully considered within an evidence‐based framework [8]. Therefore, it is imperative that medical professionals discuss the risks and benefits of cannabis use with patients, particularly among those with a history of ACEs. Understanding the association between childhood adversity and cannabis use may aid oncology providers in identifying patients who would benefit from early behavioral health intervention and closer monitoring of cannabis use.

Our study's observed association between ACEs and cannabis use highlights the potential benefit of screening for childhood adversity in cancer care. Identifying cancer survivors with a history of ACEs may help clinicians better recognize those at heightened risk for substance use and psychological distress, enabling earlier referral to trauma‐informed care, behavioral health services, or supportive interventions tailored to individual coping needs [6, 19]. Integrating psychological support into cancer survivorship care may also reduce reliance on cannabis for emotional regulation, especially when used outside of medical guidance. Trauma‐informed care has been suggested as a multilevel framework for addressing ACEs, including education, screening and referral, and trauma‐focused therapy [20]. However, outcome evaluation studies have been limited, especially with regard to substance use behaviors.

Future prospective studies should explore the feasibility and effectiveness of ACE screening protocols in oncology settings, as well as how trauma‐informed interventions might influence long‐term health outcomes. Additionally, studies examining the intersection of ACEs, cannabis use, and specific cancer‐related symptoms (e.g., pain, insomnia, anxiety) could help distinguish medical versus non‐medical motivations for use. Relatedly, future studies should explore whether ACE‐informed interventions can mitigate cannabis use driven by psychological distress rather than medical necessity. Finally, qualitative research may also offer insights into survivor perspectives on cannabis use and how early‐life trauma shapes coping preferences in the context of cancer survivorship.