Background: Adults with disabilities in the United States (U.S.) experience disproportionately higher rates of substance use than those without disabilities, with 41% reporting past-month use in 2021 compared to 25% of adults without disabilities. Despite this disparity, little research has examined how current substance use varies by disability status and type across U.S. states, regions, and territories, particularly during the COVID-19 pandemic—a period of disrupted healthcare access and increased substance use.

Methods: Data were drawn from the 2020–2023 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative survey of non-institutionalized adults. The analytic sample included 1,719,106 adults across all 50 U.S. states, District of Columbia, and three territories (Guam, Puerto Rico, and the U.S. Virgin Islands). Descriptive statistics were used to assess the prevalence of current substance use (cigarettes, e-cigarettes, alcohol, and marijuana) across regions, states, and territories. Bivariate analyses using Chi-square tests examined differences in current substance use by disability status (any vs. none) and by disability type (hearing, vision, cognitive, mobility, self-care, and independent living). Analyses accounted for the BRFSS complex sampling design and were conducted using the procsurvey freq procedure in SAS v.9.4.

Results: Substantial geographic variation emerged between 2020–2023. Among adults with disabilities, cigarette use was highest in Tennessee (49.7%) and Guam (51.2%), e-cigarette use in Kentucky (50.7%) and Guam (41.6%), alcohol use in Wisconsin (52.9%) and the U.S. Virgin Islands (41.6%), and marijuana use in Alaska (27.6%) and the U.S. Virgin Islands (27.1%). Across all states and territories, adults with disabilities reported significantly higher prevalence of cigarette, e-cigarette, and marijuana use compared to those without disabilities, but significantly lower prevalence of alcohol use. People with cognitive disabilities had significantly higher prevalence of all substance use compared to those without cognitive disabilities, while people with hearing and self-care disabilities had the lowest.

Conclusions: Current substance use varies significantly across the U.S. and its territories by disability status and type. These findings highlight the importance of tailored, evidence-based prevention and treatment strategies that consider local policy and contextual factors to reduce disparities in substance use among adults with disabilities, particularly cigarette, e-cigarette, and marijuana use during public health emergencies.