Economic instability and substance use among adults in 10 US states: Evidence from a population-based study

Background: Economic instability may shape substance use (i.e., cigarette use and cannabis use) among the adult population. However, their relationship remains poorly understood. This study estimated the prevalence of economic instability indicators (i.e., employment instability, received food stamps, food insecurity, housing insecurity, and threatened utility shutoffs), exclusive cigarette use (TU), exclusive cannabis use (CU), and cigarette-cannabis co-use (TCU), and investigated the associations between economic instability indicators and these distinct substance use patterns among adults aged ≥18 years. Methods: This study used cross-sectional population-based data from the 2023 Behavioral Risk Factor Surveillance System (BRFSS) Marijuana Use and Social Determinants and Health Equity modules, administered in 10 US states. The 2023 BRFSS achieved a response rate of 44.7%. The sample included (unweighted n = 50,481; weighted N = 24,896,969) adults ≥18 years. The outcome variables were TU, CU, and TCU. Indicators of economic instability included employment instability, receipt of food stamps, food insecurity, housing insecurity, and threats of utility shutoffs. Weighted descriptive statistics and multivariable multinomial logistic regression analyses were conducted. Results: Overall, 48.6% of the participants were aged ≤50 years, 52.6% were women, and 64.4% self-identified as non-Hispanic White. The prevalences of TU, CU, and TCU were 8.1%, 11.1%, and 3.6%, respectively. Participants experiencing employment instability, housing insecurity, or threats of utility shutoffs were more likely to engage in CU compared to TU or TCU (P ≤ 0.01). All economic instability indicators were significantly associated with TCU, with the strongest association observed for those who received food stamps (aRRR = 2.27, 95% CI: 1.75–2.94), which was also significantly associated with TU (aRRR = 1.55, 95% CI: 1.24–1.93). Threats of utility shutoffs (aRRR = 1.37, 95% CI: 1.10–1.70) and housing insecurity (aRRR = 1.27, 95% CI: 1.04–1.55) were significantly associated with CU. Conclusions: Economic instability indicators are significantly associated with cigarette and cannabis use, as well as their co-use patterns among US adults residing in the 10 participating states. Effective, targeted public health interventions to mitigate substance use risk in economically precarious populations are needed. Healthcare providers should routinely screen for economic instability to identify individuals at high risk for substance use and provide them with social services and behavioral health interventions.