(133) Rural-Urban Disparities in Tobacco, Alcohol, and Opioid Co-Use Among US Adults, 2021–2023

Background & Introduction: Polysubstance use remains a major public health challenge in the United States, with rural communities disproportionately affected by substance-related morbidity and mortality. National trends suggest that while tobacco and alcohol use have declined overall, patterns involving multiple substances, including opioids, may be shifting unevenly across geographic regions. Limited research has examined whether these rural and urban disparities in substance co-use have persisted in the post-pandemic period. This study evaluates recent national trends in tobacco, alcohol, and opioid co-use among adults from 2021 through 2023, focusing on rural disparities. Understanding these patterns is critical for developing geographically tailored prevention and treatment strategies that advance health equity and address intersecting substance use epidemics in rural populations.

Methods: This cross-sectional study used data from the 2021–2023 National Survey on Drug Use and Health (NSDUH) public-use files. Analyses were restricted to adults aged 18 years and older (n = 173,000). Survey design variables and sampling weights were applied to generate nationally representative estimates. Five outcomes were examined: (1) any co-use of two or more substances (tobacco, alcohol, opioid), (2) tobacco and alcohol, (3) tobacco and opioid, (4) alcohol and opioid, and (5) tri-use of all three substances. Weighted prevalence estimates were computed by year (2021–2023) and rurality, followed by multivariable logistic regression adjusting for demographic covariates and survey year. The key exposure was rural versus non-rural residence, and the primary outcome was any co-use versus none.

Results: The analytic sample represented approximately 281.8 million U.S. adults, of whom 16 percent resided in rural areas (n =27,900). Across all three survey years, rural adults consistently exhibited higher prevalence of co-use for every outcome assessed. In 2021, 32.6 percent of rural adults reported any co-use compared with 27.3 percent of non-rural adults. The gap persisted in 2022 (31.6 vs 27.4 percent) and 2023 (30.7 vs 27.3 percent). Tobacco and alcohol co-use displayed the largest rural–urban difference, with rates of roughly 21 to 22 percent among rural adults compared to 16 to 17 percent among non-rural adults. Tobacco and opioid co-use was approximately 9 percent in rural populations and 6 percent in non-rural populations across all years. Tri-use of tobacco, alcohol, and opioids was also more common in rural areas, averaging 6 to 7 percent versus about 5 percent in non-rural adults.

Survey-weighted logistic regression confirmed a significant and persistent rural–urban disparity in any co-use (adjusted OR = 1.23, 95% CI 1.20–1.27, p < 0.001). There was no significant year-to-year change from 2021 to 2023 (2022 vs 2021 aOR = 0.99; 2023 vs 2021 aOR = 0.98). These findings indicate that co-use of tobacco, alcohol, and opioids remains substantially more common among rural adults, with the magnitude of disparity remaining stable over time. The results suggest a persistent burden of poly-substance use in rural America even as national smoking and alcohol consumption rates decline.

Conclusion & Discussion: Rural adults continue to face elevated risk of tobacco, alcohol, and opioid co-use, with little evidence of improvement between 2021 and 2023. This stability suggests that deeply rooted behavioral and structural factors such as socioeconomic hardship, healthcare shortages, and higher stress exposure continue to sustain vulnerability in rural areas. The strong and consistent rural effect (aOR = 1.23) highlights the importance of implementing integrated, community-specific interventions that address multiple substance use behaviors simultaneously. Expanding telehealth services, medication-assisted therapy, and culturally informed counseling could reduce these disparities and promote equitable access to addiction care. Findings reinforce the need for targeted prevention and treatment strategies that reflect the unique contexts of rural communities and bridge the gap in polysubstance use outcomes across the nation.

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