Trends and Correlates of Past-Month Cannabis, Alcohol, and Tobacco Tri-Use and Intensive Tri-Use: Findings from the Behavioral Risk Factor Surveillance System, 2016-2023.

Background: Little is known about the prevalence or intensity of concurrent cannabis, alcohol, and tobacco use. To address this gap, we examined the patterns and correlates of past-month tri-use and intensive tri-use among U.S. adults. Methods: We merged 2016-2023 Behavioral Risk Factor Surveillance System data and calculated the trends, patterns, and intensity of past-month concurrent cannabis, alcohol, and tobacco use among U.S. adults (18+ years). Bivariate analysis was used to compare the characteristics of respondents reporting tri-use (versus no substance use) and intensive tri-use (versus no intensive tri-use). Multivariate logistic regression was used to identify the factors associated with these substance use patterns. Results: From 2016-2023, 2.6% of U.S. adults reported tri-use and 0.5% reported intensive tri-use. The trend in intensive tri-use increased from 0.4% in 2016 to 0.6% in 2020 (p < 0.01), but stabilized through 2023 (p = 0.19). Compared to respondents who reported no intensive substance use, respondents reporting intensive tri-use were more likely to be 25-34 years of age (AOR = 2.0, 95% CI 1.4-3.0), male (AOR = 1.7, 95% CI 1.4-2.1), unable to afford care (AOR = 1.6, 95% CI 1.3-2.1), and have only a high school degree (AOR = 0.4, 95% CI 0.3-0.6). They were less likely to be Hispanic (AOR = 0.2, 95% CI 0.1-0.3), married (AOR = 0.4, 95% CI 0.3-0.5), have a higher household income (AOR = 0.6, 95% CI 0.4-0.8), or a personal doctor/provider (AO = 0.6, 95% CI 0.5-0.8). Conclusions: Among U.S. adults, 2.6% reported cannabis, alcohol, and tobacco tri-use and 0.5% reported intensive tri-use. Being younger, male, non-Hispanic, unmarried, and lacking healthcare access were associated with these outcomes.