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Using nationally representative Youth Risk Behavior Survey data from 2019, 2021, and 2023 (39,164 students in grades 9–12), the study applies logistic regression and multinomial models. Smokeless tobacco use strongly predicts alcohol use and the reverse association is also present, but asymmetrically. Male sex, sports participation, combustible tobacco, and e-cigarette use relate to higher concurrent-use risk.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/differences-in-the-use-of-smokeless-tobacco-alcohol-and-co-use-among-us-high-school-students-analysis-of-national-youth-risk-behavior-survey-data/432229/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/differences-in-the-use-of-smokeless-tobacco-alcohol-and-co-use-among-us-high-school-students-analysis-of-national-youth-risk-behavior-survey-data/432229.png","ImageObject",300,407,{"name":92,"@type":93},"Grenda","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-03","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":39},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the study’s primary aim regarding smokeless tobacco and alcohol use?","Question",{"text":112,"@type":113},"To examine bidirectional relationships and patterns of concurrent smokeless tobacco and alcohol use among U.S. high-school students, and to assess whether demographics and behavioral factors predict concurrent versus single-substance use.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How was the analysis conducted and what dataset was used?",{"text":117,"@type":113},"Nationally representative Youth Risk Behavior Survey data were analyzed by combining three cross-sectional surveys (2019, 2021, 2023) covering 39,164 students in grades 9–12.",{"name":119,"@type":110,"acceptedAnswer":120},"What key findings describe the relationship between smokeless tobacco and alcohol use?",{"text":121,"@type":113},"The relationship is strong and bidirectional, but asymmetric: 84.5% of smokeless tobacco users reported alcohol use versus 7.8% of alcohol users reporting smokeless tobacco use, even after adjusting for covariates.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},432229,1790815293,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":39,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":52,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},7971474921005,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","RESEARCH ARTICLE  \nDifferences in the Use of Smokeless Tobacco, Alcohol, and Co-Use Among U.S. High-School Students: Analysis of National Youth Risk Behavior  \nSurvey Data  \nGanna Kostygina, PhD,1 Yoonsang Kim, PhD,1 Alex Kresovich, PhD,1 Simon Page, BA,1  \nShyanika W. Rose, PhD,2 Sherry L. Emery, PhD, MBA 1  \nIntroduction: 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.  \nResults: 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 maybe 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.  \nAJPM Focus 2026;5(1):100445. © 2025 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/)).  \nFrom the 1Social Data Collaboratory, NORC at the University of Chicago, Chicago, Illinois; and 2Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky  \nAddress correspondence to: Ganna Kostygina, Social Data Collaboratory, NORC at the University of Chicago, 55 East Monroe Street, 30th Floor, [Chicago IL 60603. E-mail:](Chicago IL 60603. E-mail: kostygina-anna@norc.org)[ kostygina-anna@norc.org](Chicago IL 60603. E-mail: kostygina-anna@norc.org).  \n2773-0654/$36.00  \n[https://doi.org/10.1016/j.focus.2025.100445](https://doi.org/10.1016/j.focus.2025.100445)  \n© 2025 The Authors. Published by Elsevier Inc. AJPM Focus 2026;5(1):100445 1  \nThis is an open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/)).  \n2 Kostygina et al / AJPM Focus 2026;5(1):100445  \nINTRODUCTION  \nTobacco and alcohol use are major public health concerns in the U.S. Tobacco use is the leading preventable cause of early death, whereas alcohol consumption ranks third.1,2","cbCair5sIcBwzijZ","https://ap.wps.com/l/cbCair5sIcBwzijZ","pdf",275703,"English","# Introduction\n# Methods\n# Results\n# Conclusions","[{\"question\":\"What is the study’s primary aim regarding smokeless tobacco and alcohol use?\",\"answer\":\"To examine bidirectional relationships and patterns of concurrent smokeless tobacco and alcohol use among U.S. high-school students, and to assess whether demographics and behavioral factors predict concurrent versus single-substance use.\"},{\"question\":\"How was the analysis conducted and what dataset was used?\",\"answer\":\"Nationally representative Youth Risk Behavior Survey data were analyzed by combining three cross-sectional surveys (2019, 2021, 2023) covering 39,164 students in grades 9–12.\"},{\"question\":\"What key findings describe the relationship between smokeless tobacco and alcohol use?\",\"answer\":\"The relationship is strong and bidirectional, but asymmetric: 84.5% of smokeless tobacco users reported alcohol use versus 7.8% of alcohol users reporting smokeless tobacco use, even after adjusting for covariates.\"}]","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 | PDF",1790658679,25]