Urban-Rural and Demographic Differences in Substance Use Among High School Students — Youth Risk Behavior Survey, United States, 2025

Adolescent substance use remains a critical public health concern. Understanding patterns of substance use might guide prevention strategies and identify populations in need of focused, tailored interventions. This report links nationally representative 2025 Youth Risk Behavior Survey data with school characteristics data to describe substance use behaviors and differences by demographic characteristics and among students in public schools for whom locale information was available, by urban-rural classification. Current (i.e., past 30-day) measures included prescription opioid misuse and use of cigarettes, cigars, smokeless tobacco, electronic vapor products, alcohol, and marijuana. Lifetime measures included prescription opioid misuse and use of electronic vapor products, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, hallucinogenic drugs, a composite of selected illicit drugs, and injection of an illegal drug. Differences by sex, race and ethnicity, grade, and school urban-rural classification were analyzed. Adjusted prevalence ratios were used to assess urban-rural differences after controlling for sex, race and ethnicity, and grade. The most commonly reported substance use behaviors were lifetime use of electronic vapor products (30.2%), followed by marijuana (25.5%) and current use of alcohol (20.3%) and electronic vapor products (16.0%). Substance use varied by sex and race and ethnicity, with differences observed in patterns across behaviors. Most observed grade-related differences reflected higher prevalence among students in higher grade levels. After adjustment, students in rural public schools had a higher prevalence of current smokeless tobacco and electronic vapor product use, as well as lifetime electronic vapor product use, than students in city and suburb or town public schools. In addition, students in rural public schools had a higher prevalence of current cigarette and cigar use than students in suburb or town public schools. These descriptive findings might guide comprehensive and multicomponent youth substance use prevention programs that engage schools, families, and communities, including tobacco and nicotine prevention strategies tailored to rural schools and communities.