Prevalence of Nicotine Pouch Use Among US Adults

Abstract

This cross-sectional study uses data from the 2022 Tobacco Use Supplement of the Current Population Survey to estimate the prevalence of adult US nicotine pouch use and the characteristics of the individuals using pouches.

Oral nicotine pouches are single-use microfiber sachets prefilled with microcrystalline powder, nicotine, and other constituents. Sales of nicotine pouches increased in the US from 126.06 to 808.14 million units (641%) between 2019 and 2022.¹ The US Food and Drug Administration regulates nicotine pouches as commercial tobacco products and is reviewing pouch marketing applications. Adult US nicotine pouch use prevalence and the characteristics of the individuals using pouches were estimated to inform regulators and clinicians about these products.

Methods

The Current Population Survey (CPS) is a monthly interview of US households conducted in person or by telephone. The Tobacco Use Supplement (TUS) was conducted in conjunction with the September 2022 CPS and this was the first time nicotine pouch questions were asked. Adult respondents who completed the CPS were randomly selected; a proxy provided responses if the target respondent was unavailable. Because proxy interviews were abbreviated, only self-interview respondents were included in this study. In September 2022, the CPS household-level response rate was 73.0% and the TUS person-level response rate was 76.8% (it was 57.6% for self-response only [when proxy responses were counted as nonresponses]).² Additional information about the CPS and TUS appear in the eMethods in the Supplement. The University of Nebraska institutional review board considered this study exempt.

Self-reported demographics, smoking status (never [<100 cigarettes during lifetime], former [≥100 cigarettes, not currently smoking], current [≥100 cigarettes, currently smoking]), and smoking characteristics (duration, frequency, past-year quit attempts, and intention to quit) were the exposure measures. Self-reported nicotine pouch ever and current use and attempts to quit smoking by switching to pouches or e-cigarettes were the outcomes (each response expressed as yes or no; the survey questions appear in the eTable in the Supplement).

Pouch use prevalence was calculated overall and by exposure variables. Logistic regression models estimated exposure variable associations with pouch use adjusted for demographic covariates. Analyses used SAS version 9.4 (SAS Institute Inc), accounting for complex sampling with survey weights that adjust for nonresponse sampling bias to approximate the US population,² with 2-tailed Benjamini-Hochberg multiple test significance corrections (study-wise false discovery rate = .05 [corrected P < .04]).³

Results

Of the 39 558 survey respondents in the sample, 51.3% were female; 11.5% were aged 18 to 24 years, 34.1% were aged 25 to 44 years, 32.1% were aged 45 to 64 years, and 22.3% were aged 65 years or older; 17.3% were Hispanic, 12.0% were non-Hispanic Black, and 8.9% were non-Hispanic other; and 9.4% reported current and 17.4% reported former smoking. Overall, 2.9% (95% CI, 2.8%-3.1%) of participants reported ever nicotine pouch use and 0.4% (95% CI, 0.31%-0.43%) reported current use.

Smoking status was associated with self-reported ever and current pouch use, with stronger associations for ever use than current pouch use. Ever pouch use prevalence was 10.8% for participants reporting current smoking (adjusted odds ratio [OR], 11.4 [95% CI, 9.8-13.2], P < .001) and 6.7% for former smoking (adjusted OR, 6.9 [95% CI, 6.0-7.8], P < .001) vs 1.1% for never smoking. Current pouch use was 1.0% for participants reporting current smoking (adjusted OR, 4.0 [95% CI, 2.6-6.1], P < .001) and 0.7% for former smoking (adjusted OR, 3.4 [95% CI, 2.4-4.7], P < .001) vs 0.2% for never smoking. Ever use and current pouch use were higher in those aged 18 to 24, 25 to 44, and 45 to 64 years vs those aged 65 years or older, males vs females, and non-Hispanic White vs the other racial and ethnic groups. Pouch ever use and current use differed across some educational and income groups, but did not differ by metropolitan residence (Table 1).

Table 1. Nicotine Pouch Use Prevalence in Overall Sample^a.

	Ever use of nicotine pouches				Current use of nicotine pouches (every day or some days)
	No. (%)b	Risk difference (95% CI)	Adjusted OR (95% CI)c	P valuec	No. (%)b	Risk difference (95% CI)	Adjusted OR (95% CI)c	P valuec
Overall	1246 (2.9)				169 (0.4)
Smoking status
Current	410 (10.8)	9.7 (8.8 to 10.6)	11.4 (9.8 to 13.2)	<.001d	40 (1.0)	0.8 (0.5 to 1.1)	4.0 (2.6 to 6.1)	<.001d
Former	533 (6.7)	5.6 (5.1 to 6.0)	6.9 (6.0 to 7.8)	<.001d	65 (0.7)	0.5 (0.4 to 0.7)	3.4 (2.4 to 4.7)	<.001d
Never	303 (1.1)	1 [Reference]	1 [Reference]		64 (0.2)	1 [Reference]	1 [Reference]
Sociodemographic variables
Age group, y
18-24	74 (2.6)	1.2 (0.7 to 1.7)	2.1 (1.7 to 2.7)	<.001d	15 (0.4)	0.4 (0.2 to 0.6)	7.0 (3.2 to 15.5)	<.001d
25-44	573 (4.0)	2.6 (2.2 to 2.9)	3.7 (3.1 to 4.4)	<.001d	101 (0.6)	0.6 (0.4 to 0.7)	11.4 (6.0 to 21.9)	<.001d
45-64	400 (3.0)	1.6 (1.3 to 1.9)	2.5 (2.1 to 2.9)	<.001d	43 (0.3)	0.2 (0.1 to 0.3)	4.2 (2.1 to 8.3)	<.001d
≥65	199 (1.4)	1 [Reference]	1 [Reference]		10 (0.1)	1 [Reference]	1 [Reference]
Sex
Male	917 (4.5)	3.1 (2.8 to 3.4)	3.2 (2.9 to 3.7)	<.001d	145 (0.7)	0.6 (0.5 to 0.7)	8.4 (5.6 to 12.6)	<.001d
Female	329 (1.4)	1 [Reference]	1 [Reference]		24 (0.1)	1 [Reference]	1 [Reference]
Race and ethnicitye
Hispanic	60 (1.1)	−2.8 (−3.2 to −2.5)	0.2 (0.18 to 0.29)	<.001d
Non-Hispanic
Black	56 (1.2)	−2.7 (−3.0 to −2.4)	0.3 (0.22 to 0.33)	<.001d
White	1068 (3.9)	1 [Reference]	1 [Reference]		156 (0.5)	1 [Reference]	1 [Reference]
Otherf	62 (1.9)	−2.1 (−2.6 to −1.5)	0.5 (0.3 to 0.6)	<.001d	13 (0.1)g	−0.5 (−0.6 to −0.4)g	0.1 (0.07 to 0.19)g	<.001d
Education
No high school	64 (1.7)	−0.8 (−1.2 to −0.4)	1.1 (0.8 to 1.4)	.59	9 (0.2)	−0.1 (−0.3 to 0.1)	1.1 (0.6 to 2.2)	.67
High school graduate	336 (3.0)	0.5 (0.2 to 0.9)	1.4 (1.2 to 1.6)	<.001d	50 (0.4)	0.1 (−0.1 to 0.2)	1.2 (0.8 to 1.8)	.29
Some college	449 (3.8)	1.4 (1.0 to 1.7)	1.8 (1.6 to 2.0)	<.001d	52 (0.4)	0.04 (−0.1 to 0.2)	1.2 (0.8 to 1.6)	.36
College graduate	397 (2.5)	1 [Reference]	1 [Reference]		58 (0.3)	1 [Reference]	1 [Reference]
Household income, $
≤49 999	474 (2.7)	−0.4 (−0.73 to −0.02)	1.2 (1.1 to 1.4)	.01d	58 (0.3)	−0.01 (−0.1 to 0.1)	1.6 (1.1 to 2.5)	.02d
50 000-99 999	395 (2.9)	−0.2 (−0.5 to 0.2)	1.0 (0.9 to 1.2)	.55	61 (0.4)	0.1 (−0.1 to 0.2)	1.4 (0.9 to 2.0)	.11
≥100 000	377 (3.1)	1 [Reference]	1 [Reference]		50 (0.4)	1 [Reference]	1 [Reference]
Metropolitan residence
No	300 (3.8)	1.0 (0.6 to 1.5)	1.1 (1.0 to 1.3)	.07	37 (0.4)	0.1 (−0.1 to 0.2)	0.9 (0.6 to 1.4)	.64
Yes	946 (2.8)	1 [Reference]	1 [Reference]		132 (0.4)	1 [Reference]	1 [Reference]

Abbreviation: OR, odds ratio.

^a Included self-respondents (n = 39 558) with nicotine pouch use data (analytic sample n = 39 006).² There were missing data for smoking status (n = 174), which was addressed by list-wise deletion.

^b Weighted percentage within the row.

^c Estimate from multivariable logistic regression models with simultaneous adjustment for all the sociodemographic variables.

^d Statistically significant after Benjamini-Hochberg multiple test correction was used to maintain study-wise false discovery rate of .05 (corrected P < .04).

^e Assessed to estimate demographic characteristics. Race was self-identified by selecting all that apply among the following: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, or “Other.” Hispanic ethnicity was self-identified.

^f The “Other” category includes those who self-identified as Asian American, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and those who selected 2 or more race categories.

^g Due to small numbers within each row for race and ethnicity, all participants with a race and ethnicity other than Non-Hispanic White were combined into 1 group.

Participants reporting current smoking (n = 3976) with vs without past-year quit attempts reported higher pouch ever use (12.5% vs 9.6%, respectively; adjusted OR, 1.4 [95% CI, 1.1-1.7], P = .004) and current use (1.6% vs 0.6%; adjusted OR, 3.2 [95% CI, 1.8-5.7], P < .001). Not smoking daily vs smoking daily was associated with lower reported pouch ever use (8.8% vs 11.4%, respectively; adjusted OR, 0.7 [95% CI, 0.6-0.9], P = .002), but not current use. Quit intention was associated with self-reported pouch ever use. Shorter smoking duration was associated with self-reported pouch current use (Table 2).

Table 2. Prevalence of Nicotine Pouch Use by Smoking Characteristics^a.

	Ever use of nicotine pouches				Current use of nicotine pouches (every day or some days)
	No. (%)b	Risk difference (95% CI)	Adjusted OR (95% CI)c	P valuec	No. (%)b	Risk difference (95% CI)	Adjusted OR (95% CI)c	P valuec
Smoking duration, y
<20	89 (11.8)	1.1 (−1.4 to 3.6)	0.8 (0.6 to 1.0)	.08	13 (1.8)	1.0 (0.1 to 1.9)	2.6 (1.4 to 4.6)	.002d
≥20	317 (10.7)	1 [Reference]	1 [Reference]		27 (0.8)	1 [Reference]	1 [Reference]
Current smoking frequency
Not daily	84 (8.8)	−2.6 (−4.3 to −0.9)	0.7 (0.6 to 0.9)	.002d	16 (1.6)	0.8 (−0.1 to 1.6)	1.9 (0.98 to 3.83)	.06
Daily	326 (11.4)	1 [Reference]	1 [Reference]		24 (0.8)	1 [Reference]	1 [Reference]
Past-year quit attempt
Yes	188 (12.5)	2.9 (0.9 to 5.0)	1.4 (1.1 to 1.7)	.004d	24 (1.6)	1.1 (0.4 to 1.7)	3.2 (1.8 to 5.7)	<.001d
No	222 (9.6)	1 [Reference]	1 [Reference]		16 (0.6)	1 [Reference]	1 [Reference]
Intention to quit smoking within next 6 mo
Yes	188 (12.4)	2.6 (0.7 to 4.5)	1.4 (1.1 to 1.7)	.003d	23 (1.2)	0.4 (−0.2 to 0.9)	1.6 (1.0 to 2.8)	.07
No	215 (9.8)	1 [Reference]	1 [Reference]		17 (0.9)	1 [Reference]	1 [Reference]

Abbreviation: OR, odds ratio.

^a The sample included respondents who self-reported currently smoking cigarettes (n = 3976) with nicotine pouch use data (analytic sample n = 3836).² There were missing data for smoking frequency (n = 140) and smoking duration (n = 246), which was addressed by list-wise deletion.

^b Weighted percentage within the row.

^c Estimate from multivariable logistic regression models testing each exposure variable separately after simultaneous adjustment for all sociodemographic variables in Table 1. The variance inflation factor ranged from 1.0 to 1.1 for most of the covariates; however, it was 1.5 for age and smoking duration. For the smoking duration logistic regression models, age was excluded as a covariate due to multicollinearity.

^d Statistically significant after Benjamini-Hochberg multiple test correction was used to maintain study-wise false discovery rate of .05 (corrected P < .04).

Among those reporting past-year attempts to quit smoking (n = 1592), switching to e-cigarettes was more common (21.6% [95% CI, 19.7%-23.7%]) than switching to nicotine pouches (5.2% [95% CI, 4.2%-6.4%]).

Discussion

In 2022, US adults infrequently reported ever or current use of nicotine pouches. There was higher reported pouch use in younger age groups, males, and non-Hispanic White respondents. Even though appreciable numbers of adults who reported smoking also reported ever pouch use, current pouch use was uncommon, especially in those with daily smoking. Individuals currently smoking who attempted to quit were more likely to report having used or are currently using pouches than those without any quit attempts, although reporting pouch use for that reason was infrequent.

Pouch use may be associated with the adverse effects of nicotine dependence, mouth lesions, and nausea,⁴ but pouch use does avoid respiratory exposure and some of the tobacco toxins present in cigarettes.⁵ Given prior evidence that pouches did not substantially relieve cigarette cravings for those reporting smoking daily,⁶ alongside the current study’s findings, whether pouches encourage switching from cigarettes warrants future empirical inquiry.

Limitations include cross-sectional design, self-report reliance, and small sample sizes for current pouch use and other characteristics. Further surveillance of nicotine pouch use is merited.

Section Editors: Kristin Walter, MD, and Jody W. Zylke, MD, Deputy Editors; Karen Lasser, MD, MPH, Senior Editor.

Supplement 1.

eMethods

eTable. Survey Questions and Operational Definition of Outcome Measures

eReferences

Supplement 2.

Data sharing statement