Differences in the Use of Smokeless Tobacco, Alcohol, and Co-Use Among U.S. High-School Students: Analysis of National Youth Risk Behavior Survey Data

Introduction This study was aimed to examine the bidirectional relationships and patterns of concurrent smokeless tobacco and alcohol use among U.S. high-school students, investigating whether demographic characteristics and behavioral factors differentially predict concurrent versus single substance use of smokeless tobacco or alcohol (referred to as either-alone use in the remaining parts of this paper). Methods Analysis of nationally representative Youth Risk Behavior Survey data was perfomed, combining 3 cross-sectional surveys (2019, 2021, 2023) from 39,164 students in Grades 9–12. Logistic regression examined the bidirectional smokeless tobacco–alcohol associations, whereas multinomial models compared the characteristics of concurrent users, users of smokeless tobacco or alcohol alone, and nonusers. Results The authors found a strong bidirectional relationship: smokeless tobacco users had 3.8 times higher odds of alcohol use than non-users, and similarly, alcohol users had 4.5 times higher odds of smokeless tobacco use than non-users, adjusting for covariates. This relationship was asymmetric: 84.5% of smokeless tobacco users reported alcohol use, whereas only 7.8% of alcohol users reported smokeless tobacco use. Males had lower odds of either-alone use but 2.2 times greater odds of concurrent use (relative to neither use) than females. Past-year sports participation was associated with smokeless tobacco use and alcohol use as well as concurrent use, with athletes showing 2.2 times higher odds of concurrent use relative to neither use and 1.4 times higher odds of concurrent use relative to either-alone use than nonathletes. Furthermore, combustible tobacco users and E-cigarette users were more likely to be concurrent smokeless tobacco and alcohol users. Conclusions The strong yet asymmetric relationship suggests that smokeless tobacco users may be a crucial target for alcohol prevention. The distinct risk patterns for concurrent use—particularly among males and other tobacco users—indicate that prevention strategies should likely differ between concurrent and either-alone use. Results also suggest reconsidering how substance use prevention is approached in sports contexts, particularly given the strong association between athletic participation and concurrent smokeless tobacco and alcohol use.