Abstract
Background:
Nicotine pouches (NPs) are one of the fastest growing tobacco product categories in the in the United States (US). We estimated the prevalence of NP use in 2022 and 2024 among US adults with established nicotine product use.
Methods:
Data are from the 2022 (N=2087) and 2024 (N=2083) US ITC Smoking and Vaping Surveys. A nationally representative sample of adults (≥18 years) who smoked cigarettes and/or vaped nicotine or quit smoking and/or vaping completed at least one survey. Using weighted data, generalized estimating equation models were applied to estimate ever and current (≥monthly) use. Data from both surveys were pooled to examine characteristics related to NP ever-and current-use.
Results:
Between 2022 and 2024, the prevalence of NP ever-use increased by 42% (16.1%–22.8%, p<0.001), and current use increased by 66% (4.7%–7.8%, p=0.007). NP ever-use increased significantly among all age groups, except adults aged 25–39. Current use increased among all age groups, but only significantly for adults aged 18–24 and 55+. Compared to all other age groups, adults aged 18–24 had an 11.8% greater increase in current use (p=0.045). In the pooled analyses, current NP use was significantly higher among those who were male, were using other smokeless tobacco products (p<0.001), were smoking and vaping (dual use), exclusively vaping, or had quit smoking and/or vaping compared to adults who were exclusively smoking (p<0.001). There were non-significant increases in frequency of daily non-daily and occasional use.
Conclusions:
We found a significant increase in NP ever and current use between 2022 and 2024 among adults with established nicotine product use, consistent with national sales trends. Further research is needed to determine whether adults are using NPs as a tool to quit smoking or sustain abstinence after quitting.
Keywords: Nicotine, nicotine pouches, adults, tobacco, smoking, vaping
INTRODUCTION
Alternatives to combustible cigarettes have dramatically changed the nicotine product market. With global cigarette smoking consumption and prevalence on the decline,1,2 several tobacco companies have developed and marketed smokefree tobacco/nicotine products.3 More recently, tobacco-free oral nicotine pouches (NPs) have become one of the fastest growing tobacco product categories in the United States (US). National4–6–8 and industry9,10 data have shown a marked increase in NP sales over the last five years; however, population-level prevalence of NP use was low overall between 2020 and 2023;11–15 with prevalence being higher among individuals with a history of nicotine use.12–16
The growth and rising popularity of NPs in the US are likely due to many factors, including lower cost relative to other tobacco products, increased demand for smokefree nicotine products, perceived convenience, and the availability of a variety of nicotine strengths and flavors.5,16–21 NPs may also offer people who smoke a less harmful way to consume nicotine.18 Unlike traditional tobacco products, nicotine pouches do not produce tar or other harmful byproducts of combustion, potentially leading to reduced exposure to carcinogens and respiratory irritants. Two reviews have reported that the chemical composition of NPs suggests fewer harmful and potentially harmful compounds at lower levels than cigarettes,16,17 and other smokeless tobacco products.16,17,22–24 There is limited evidence on nicotine e-cigarettes (ECs) and NPs’ relative toxicant profiles, but it is reasonable to assume that NPs would be less harmful due to the absence of inhalation.16,25,26 Based on the current evidence demonstrating that the commercial sale of NPs is appropriate for the protection of public health (and considering the risks and benefits of NPs to the population as a whole), the FDA Center for Tobacco Products issued marketing authorization for 20 ZYN NPs.27
In addition to NPs being a possible lower-risk nicotine product, some pharmacokinetic studies have shown that NPs may deliver nicotine as quickly as snus and moist snuff,27 and NPs with a higher nicotine content may deliver a sufficient amount of nicotine compared to cigarettes.17,28 Studies have also shown that using NPs can help reduce cravings to smoke cigarettes.17,18 Although it remains unclear if NPs can be a substitute for cigarettes (or other inhalable nicotine products), descriptive studies have found higher rates of NP use among adults who formerly smoked cigarettes,13,15 which has similarly been found for ECs.29
Because of the paucity of evidence from population studies on NPs and their interaction with cigarettes, including use of NPs among those who smoke versus those who do not (especially youth), the net public health impact of NPs is currently unclear. In the US, the potential public health impact of NPs is especially relevant because awareness and use of NP has increased in recent years.16,17,30 Similar to ECs,31 NPs come in a wide variety of appealing flavors and nicotine strengths,17 and coupled with aggressive marketing campaigns,16,32–34 there is potential to increase youth and young adults interest in using them. However, studies have also shown that NPs may be particularly appealing to adults who smoke or vape for various reasons, including to quit smoking or vaping, to help maintain abstinence after quitting, and/or to use NPs in places where smoking and vaping are prohibited.16,17,35–37
Given the recent growth of the NP market place, coupled with the potential for NPs to be a lower harm alternative to cigarettes, and possibly ECs, this study sought to contribute to the evidence on NP use trends among a nationally representative sample of US adults who smoked and/or vaped or quit smoking and/or vaping by: (1) estimating changes between 2022 and 2024 in prevalence of ever and current-use of NPs; (2) describing the frequency of any use of nicotine pouches (daily, non-daily or occasional use) by age group and smoking/vaping status; (3) examining characteristics of having ever-used or currently use NPs; and (4) identifying characteristics of daily use among those who reported any frequency of current NP use in 2022 and/or 2024.
METHODS
Study overview
Longitudinal data for this study are from Wave 4 (August 4 to December 19, 2022) and Wave 5 (July 17 to November 25, 2024) of the US arm of the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Survey. US respondents were recruited from the Ipsos KnowledgePanel, which is a probability-based online panel that provides a statistically valid representation of the US population. Participants are randomly selected by telephone or mail to residential addresses. Individuals in selected households are invited to participate in the web-enabled KnowledgePanel. Consenting panelists receive unique log-in information for accessing surveys online and then are sent emails each month inviting them to participate in research.
Eligible respondents for the ITC 4CV Survey include adults (≥18 years) who smoke cigarettes at least monthly and smoked at least 100 cigarettes in their lifetime; recently quit smoking (smoked at least monthly previously, quit in the past 24 months, and previously smoked at least 100 cigarettes in their lifetime); and/or at least weekly use of another non-combustible nicotine product: ECs, NPs, heated tobacco products, and/or snus. Approximate quota targets (based on region, sex, and/or age) were established proportional to national benchmarks to ensure appropriate distributions in the final sample.
Respondents completed an online questionnaire in English that took on average about 48 minutes to complete at Wave 4 and 44 minutes at Wave 5. Respondents were provided with 28 US dollars for completing each survey. All panelists who completed a valid Wave 4 survey were invited back to participate at Wave 5. Respondents lost to follow-up were replaced at each wave by eligible new panelists using the same sampling procedures.
A total of 2190 US adults completed the Wave 4 survey (the retention rate from Wave 3 was 50.2%). Response rates (the number of eligible respondents who completed the survey divided by the estimated number of eligible respondents that were selected/contacted) and cooperation rates (the proportion of eligible respondents who complete the survey) for those newly recruited at Wave 4 were 58.2% and 93.4% respectively. At Wave 5, 2184 completed the survey: 69.4% of respondents were retained from Wave 4, and the response and cooperation rates for those newly recruited at Wave 5 were 78.4% and 97.1% respectively.
The survey protocols and all materials, including the survey questionnaires, were cleared for ethics by the Research Ethics Board, University of Waterloo, Canada (REB#20803/30570). Ethics clearance at the Medical University of South Carolina was waived due to minimal risk.
Weighting procedure
All survey data were weighted to make the US sample as representative as possible of adults who smoke cigarettes, vape nicotine, or quit smoking. This process also compensates for potential biases arising from the sampling design (e.g., quotas, over/under sampling) and non-response. A raking algorithm was used to calibrate the sampling weights to benchmark population figures on smoking and vaping obtained from the US National Health Interview Surveys. This calibration was done based on smoking status and vaping status, sex, age, geographic regions, ethnicity and education.
Further details about the IT 4CV Survey sampling and weighting procedures can be found in the Wave 4 and Wave 5 technical reports. 38,39
Eligible respondents for the current study
Respondents were eligible for this study if they: (1) exclusively smoked cigarettes at least monthly, (2) exclusively vaped ECs at least monthly, (3) smoked and vaped (both at least monthly, dual use), or (4) quit smoking and/or vaping. All respondents also were required to have completed the survey questions on ‘ever-use’ or ‘current use’ of NPs. Eligible respondents included 2087 adults at Wave 4 (2022) and 2083 at Wave 5 (2024). All respondents herein completed at least one survey, and provided informed consent electronically before proceeding to take the survey.
Measures
Outcome measures: ever-use and current use of NPs
NPs were described in the surveys with the statement “tobacco-free oral nicotine products such as Zyn, On!, or Velo, pouches, lozenges, or discs. These products do not produce spit and are not approved for smoking cessation treatments”. Respondents were shown a photo and provided with a general description of various brands (see Supplemental Figure 1). All respondents were asked whether they had ever heard of tobacco-free oral nicotine products and if they answered “yes”, were subsequently asked whether they ever used NPs (lifetime use) and whether they currently use NPs (daily, weekly, monthly, less than monthly, or not at all). Respondents could also select “don’t know”. Responses for all three outcomes were categorized as ‘yes’ vs. ‘no/don’t know’ for all analyses. Respondents who never heard of NPs were categorized as ‘no’ for both outcomes.
Independent variables/covariates
Sociodemographic variables:
Sociodemographic data were collected by commercial panel firms and verified at the time of survey completion. Sociodemographics included in this study were age (18–24, 25–39, 40–54 and ≥55 years), sex (male or female), race/ethnicity, highest level of education, and annual household income. Age was categorized as 18–24, 25–39, 40–54, and ≥55 years. Race/ethnicity was a derived variable that was dichotomized as White or non-White. Education was categorized into three levels: low (high school or lower), moderate (technical/community college, some university), or high (higher than university degree). Income was categorized into three levels on the basis of annual income: low (≤$29,999), moderate ($30,000–$59,999), and high (≥$60,000).
Smoking and vaping status:
Smoking and vaping status were determined at the initial recruitment screening stage. All potential participants were asked if they smoked cigarettes and/or vaped ECs: (1) “How often do you currently smoke ordinary cigarettes (either factory-made/pack or roll-your-own)?” and (2) “How often do you currently vape?” Response options ranged from ‘daily’ to ‘never’.
Current use of other smokeless tobacco (SLT) products:
Respondents were asked if they were currently using other SLT products (dip, chew, snuff, snus). Current use was defined as at least monthly and all products were combined into one category (‘yes’ vs. ‘no/not stated’).
Wave of recruitment:
Respondents were included if they were from a previous cohort (≤2015, 2016, 2018, 2020), or if they were newly replenished in 2022 or 2024.
Time-in-sample (TIS):
Time-in-sample (TIS) refers to the number of times a respondent has completed a survey. Respondents were categorized as: first time in the survey (replenishment sample), completed two surveys (cohort sample) or completed more than two surveys (cohort sample). TIS was used as a control variable in all models.
Statistical analyses
Unweighted descriptive statistics were used to describe the study sample at each survey wave. All other analyses were conducted on weighted data. Generalized estimating equations (GEE) were used to fit logistic regression models, which accounted for within-person correlation over time and the complex survey design. Rescaled cross-sectional weights were used and adjusted for in the GEE analyses. To ensure within-individual consistency, the GEE models required equal weighting of repeated measurements for each individual. Therefore, for participants who completed both survey waves, their baseline rescaled cross-sectional weights were applied at both time points. The GEE models also incorporated survey design information (e.g., strata) and accounted for within-subject correlation using an exchangeable working correlation matrix. The predicted marginal standardization method was used to generate prevalence estimates. Statistical significance and confidence intervals (CI) were computed at the 95% CI. Missing data were coded as missing. Adjusted odds ratios (aORs) are presented for all comparisons in ever-use and current use of NPs. All analyses were conducted in SAS-Callable SUDAAN (Version 11).
In the first set of analyses, GEE regression analyses were conducted to estimate prevalence of ever-use and current use of NPs among adults who currently or formerly smoked and/or vaped. We tested whether prevalence estimates differed between 2022 and 2024 among all adults, as well as within each characteristic. All models adjusted for age, sex, TIS and smoking and vaping status. For the second set of analyses, we pooled 2022 and 2024 data and conducted multivariable regression analyses to test characteristics related to (1) ever-use, and (2) current use of NPs (main effect models). Thereafter, we tested interactions between survey wave and each of the explanatory variables (interaction model) for current NP use, with a focus on age and smoking and vaping status (exclusive, dual, quit) to examine whether the associations between these variables and NP use changed over time.
Supplemental analyses were conducted using GEEs to examine changes in the frequency of any use of NPs: daily, non-daily (daily/weekly), or occasional use (less than monthly) in 2022 and 2024, overall and by age groups and by smoking/vaping status. All respondents were included in this set of analyses (including adults who do not use NPs) to get prevalence estimates of any NP use among US adults who smoke/vape or quit smoking/vaping. Models adjusted for age, sex, TIS, and smoking and vaping status. We then conditionally examined predictors of daily NP use (vs. current non-daily use: weekly/monthly/occasionally) with a multivariable logistic regression model (2022 and 2024 data were pooled). Only those who reported any current use were included in the model (n=320).
RESULTS
Respondents’ characteristics are presented in Table 1. In brief, the majority of respondents were older (ages 40+), identified as White Non-Hispanic, and smoked cigarettes daily. Half of the sample had never vaped ECs.
Table 1.
Respondents’ sample characteristics in 2022 and 2024.
| Variable | 2022 (Wave 4) | 2024 (Wave 5) | ||
|---|---|---|---|---|
|
| ||||
| n | % | n | % | |
| Sex | ||||
| Male | 1034 | 49.5 | 1061 | 50.9 |
| Female | 1053 | 50.5 | 1022 | 49.1 |
| Age group | 58 | 2.8 | 57 | 2.7 |
| 18–24 | ||||
| 25–39 | 479 | 23.0 | 479 | 23.0 |
| 40–54 | 567 | 27.2 | 582 | 27.9 |
| 55+ | 983 | 47.1 | 965 | 46.3 |
| Income | 674 | 32.3 | 601 | 28.9 |
| Low | ||||
| Moderate | 563 | 27.0 | 534 | 25.6 |
| High | 850 | 40.7 | 948 | 45.5 |
| Education | 737 | 35.3 | 770 | 37.0 |
| Low | ||||
| Moderate | 860 | 41.2 | 836 | 40.1 |
| High | 490 | 23.5 | 477 | 22.9 |
| Race/ethnicity | ||||
| White Non-Hispanic | 1560 | 74.7 | 1540 | 73.9 |
| Black Non-Hispanic | 232 | 11.1 | 239 | 11.5 |
| Hispanic | 184 | 8.8 | 184 | 8.8 |
| Other | 111 | 5.3 | 120 | 5.8 |
| Cigarette smoking status | ||||
| Daily | 1203 | 57.6 | 1154 | 55.4 |
| Non-daily (weekly/monthly) | 190 | 9.1 | 176 | 8.45 |
| Quit smoking | 647 | 31.0 | 715 | 34.3 |
| Never smoked | 47 | 2.25 | 38 | 1.82 |
| Vaping (e-cigarette) status | ||||
| Daily | 430 | 20.6 | 466 | 22.4 |
| Non-daily (weekly/monthly) | 179 | 8.6 | 220 | 10.6 |
| Quit vaping | 358 | 17.2 | 355 | 17.0 |
| Never vaped | 1120 | 53.7 | 1042 | 50.0 |
| Smoking /vaping status * | ||||
| Currently smoking cigarettes/never vaped ECs | 871 | 41.7 | 795 | 38.2 |
| Currently smoking cigarettes/quit vaping ECs | 267 | 12.8 | 238 | 11.4 |
| Currently smoking cigarettes and vaping (dual use) | 255 | 12.2 | 297 | 14.3 |
| Quit smoking cigarettes/currently vaping ECs | 318 | 15.2 | 363 | 17.4 |
| Quit smoking cigarettes/never vaped ECs | 238 | 11.4 | 235 | 11.3 |
| Never smoked cigarettes/currently vaping ECs | 36 | 1.7 | 26 | 1.2 |
| Quit smoking cigarettes/quit vaping ECs | 91 | 4.4 | 117 | 5.6 |
| Quit vaping ECs/never smoked cigarettes | 11 | 0.5 | 12 | 0.6 |
| Current other smokeless tobacco use | 83 | 4.0 | 82 | 3.9 |
| Yes | ||||
| No/not stated | 2004 | 96.0 | 2001 | 96.1 |
| Time-in-sample | ||||
| First time in the survey | 912 | 43.7 | 653 | 31.3 |
| Two times in the survey | 339 | 16.2 | 546 | 26.2 |
| More than two times in the survey | 836 | 40.1 | 884 | 42.4 |
Table 1 Footnotes. Data are unweighted and unadjusted.
Smoking and vaping status were combined for all other analyses: exclusive smoking (n=1138); dual use (n=255); exclusive vaping (n=354); or quit smoking and/or vaping (n=340). EC: e-cigarette. Current other smokeless tobacco use: snus, dip, chew.
Changes in ever-use of NPs among adults who currently or formerly smoked/vaped and current use
Table 2 presents the estimates of ever-use of NPs in 2022 and 2024 and differences overall and by characteristics. Between 2022 and 2024, the prevalence of ever-use of NPs increased by 42% from 16.1% to 22.8% (p<0.0001). By each characteristic, there were significant increases in ever-use among males (21.2% to 30.0%, p<0.001), those aged 18–24 (10.3% to 39.5%, p<0.001), 40–54 (16.2% to 24.0%, p<0.01) and 55+ (10.6% to 15.3%, p<0.01), those with high household income (16.9% to 26.0%, p<0.001), among all educational groups: low (14.4% to 20.5%, p=0.01), moderate (17.3% to 24.5%, p<0.01) and high (19.5% to 27.8%, p<0.01, those who identified as White Non-Hispanic (17.1% to 23.8%, p<0.001) or Hispanic (11.2% to 19.2%, p=0.05), those who exclusively smoked (11.9% to 16.8%, p=0.02) or exclusively vaped (15.0% to 27.8%, p<0.01), and those not currently using other SLTs or did not state SLT use (14.4% to 21.7%, p<0.0001).
Table 2.
Ever-use and current use of tobacco-free oral nicotine pouches among adults in the United States who currently smoke cigarettes and or vape nicotine or quit smoking and/or vaping in 2022 and 2024.
| Ever used, % (SE) | Current use, % (SE) | |||||
|---|---|---|---|---|---|---|
|
| ||||||
| 2022 | 2024 | p-value | 2022 | 2024 | p-value | |
| Overall | 16.1 (1.2) | 22.8 (1.4) | <0.0001 | 4.7 (0.7) | 7.8 (1.1) | 0.007 |
| Sex | ||||||
| Male | 21.2 (1.9) | 30.0 (2.0) | <0.001 | 6.3 (1.1) | 10.3 (1.5) | 0.01 |
| Female | 9.2 (1.2) | 13.1 (1.7) | 0.05 | 2.2 (0.8) | 3.7 (1.3) | 0.29 |
|
| ||||||
| Age group | ||||||
| 18–24 | 10.3 (4.5) | 39.5 (8.1) | <0.001 | 1.2 (0.9) | 15.0 (5.9) | 0.02 |
| 25–39 | 22.3 (2.6) | 24.5 (2.5) | 0.48 | 6.7 (1.4) | 8.5 (1.6) | 0.30 |
| 40–54 | 16.2 (2.0) | 24.0 (2.2) | <0.01 | 5.0 (1.2) | 6.6 (1.2) | 0.31 |
| 55+ | 10.6 (1.4) | 15.3 (1.6) | <0.01 | 2.5 (1.0) | 5.0 (1.2) | <0.01 |
|
| ||||||
| Income | ||||||
| Low | 14.9 (2.1) | 20.1 (2.5) | 0.09 | 2.7 (0.8) | 3.4 (1.7) | 0.70 |
| Moderate | 16.8 (2.4) | 20.2 (2.4) | 0.23 | 4.8 (1.4) | 7.2 (1.7) | 0.20 |
| High | 16.9 (1.9) | 26.0 (2.1) | <0.001 | 5.7 (1.2) | 9.9 (1.5) | 0.01 |
|
| ||||||
| Education | ||||||
| Low | 14.4 (1.9) | 20.5 (20) | 0.01 | 3.7 (1.0) | 6.6 (1.5) | 0.09 |
| Moderate | 17.3 (2.1) | 24.5 (2.4) | <0.01 | 4.7 (1.4) | 8.7 (1.7) | 0.01 |
| High | 19.5 (2.5) | 27.8 (2.8) | <0.01 | 6.7 (1.5) | 9.4 (1.8) | 0.22 |
|
| ||||||
| Race/ethnicity | ||||||
| White Non-Hispanic | 17.1 (1.5) | 23.8 (1.7) | 0.001 | 4.6 (0.9) | 8.0 (1.2) | 0.01 |
| Black Non-Hispanic | 15.9 (3.6) | 21.4 (3.7) | 0.15 | 7.4 (3.0) | 7.5 (2.8) | 0.97 |
| Hispanic | 11.2 (3.8) | 19.2 (4.3) | 0.05 | 3.1 (1.4) | 8.0 (3.7) | 0.23 |
| Other | 14.9 (4.5) | 22.0 (4.9) | 0.23 | 4.8 (3.1) | 6.4 (3.2) | 0.63 |
|
| ||||||
| Current smoking/vaping status | ||||||
| Exclusive smoking | 11.9 (1.4) | 16.8 (1.6) | 0.02 | 0.8 (0.3) | 2.2 (0.6) | 0.03 |
| Dual use (cigarettes + ECs) | 26.1 (3.4) | 30.7 (3.3) | 0.32 | 11.3 (2.3) | 10.6 (2.0) | 0.80 |
| Exclusive vaping | 15.0 (3.0) | 27.8 (3.3) | <0.01 | 2.0 (1.2) | 8.1 (2.3) | 0.02 |
| Quit smoking and/or vaping | 21.7 (3.0) | 25.9 (3.2) | 0.26 | 12.1 (2.5) | 16.0 (2.7) | 0.20 |
|
| ||||||
| Current (other) smokeless tobacco use | ||||||
| Yes | 51.0 (8.6) | 49.5 (9.2) | 0.90 | 20.9 (5.7) | 25.5 (7.1) | 0.58 |
| No/not stated | 14.4 (1.3) | 21.7 (1.4) | <0.0001 | 3.3 (0.7) | 6.5 (1.1) | <0.01 |
Data are weighted. Generalized estimating equations were conducted to estimate prevalence of ever-use and current use of NPs among adults who currently or formerly smoked and/or vaped. Models adjusted for age group, sex, time-in-sample and smoking/vaping status. Ever used: ever tried an NP, even once. Current use: use NPs at least monthly. Current other smokeless tobacco use: snus, dip, chew, snuff. P-value: indicates a significant difference between 2022 and 2024. Respondents who has never heard of NP were categorized as “no” for both outcomes. SE: Standard error. ECs: e-cigarettes.
Table 3 presents the pooled adjusted regression analyses comparing characteristics associated with having ever-used an NP. Ever-use was significantly higher among males (aOR=2.57, 95% CI: 1.92–3.44 vs. females) and those using other SLT products (aOR=5.13, 95% CI: 2.82–9.33 vs. no current SLT use or not stated). Compared to adults who were exclusively smoking, those who were dual using cigarettes and ECs (aOR=1.97, 95% CI: 1.40–2.76), exclusively vaping (aOR=1.59, 95% CI: 1.11–2.29), or quit smoking/vaping (aOR=1.47, 95% CI:1.04–2.07) were more likely to have tried an NP. Adults who were ages 55+ were less likely to have ever tried an NP (aOR=0.41, 95% CI:0.21–0.82 vs. ages 18–24). There were no significant differences in ever-use by income, education, and race/ethnicity (all main effects tests were p≥0.05).
Table 3.
Characteristics associated with having ever-used NPs among US adults who currently smoke cigarettes and/or vape nicotine or quit smoking and/or vaping
| Variables | n | % Ever used | aOR (95% CI) | p-value |
|---|---|---|---|---|
| Wave | <0.001 | |||
| Wave 4 (2022) | 1906 | 16.0 | Reference | |
| Wave 5 (2024) | 1916 | 22.8 | 1.64 (1.32 – 2.04) | |
|
| ||||
| Sex | <0.001 | |||
| Female | 1889 | 12.1 | Reference | |
| Male | 1933 | 24.6 | 2.57 (1.92 – 3.44) | |
|
| ||||
| Age group | <0.001 | |||
| 18–24 | 107 | 24.4 | Reference | |
| 25–39 | 889 | 23.4 | 0.94 (0.49 – 1.81) | |
| 40–54 | 1056 | 19.6 | 0.73 (0.38 – 1.42) | |
| 55+ | 1770 | 12.7 | 0.41 (0.21 – 0.82) | |
|
| ||||
| Income | 0.82 | |||
| Low | 1135 | 18.8 | Reference | |
| Moderate | 1025 | 19.0 | 1.01 (0.71 – 1.45) | |
| High | 1662 | 20.2 | 1.11 (0.77 – 1.58) | |
|
| ||||
| Education | 0.07 | |||
| Low | 1367 | 17.2 | Reference | |
| Moderate | 1549 | 21.2 | 1.34 (0.96 – 1.86) | |
| High | 906 | 23.2 | 1.53 (1.05 – 2.23) | |
|
| ||||
| Race/ethnicity | 0.45 | |||
| White Non-Hispanic | 2861 | 20.5 | Reference | |
| Black Non-Hispanic | 421 | 17.2 | 0.78 (0.51 – 1.21) | |
| Hispanic | 332 | 15.7 | 0.69 (0.38 – 1.25) | |
| Other | 208 | 17.7 | 0.81 (0.48 – 1.37) | |
|
| ||||
| Smoking/vaping status | <0.001 | |||
| Exclusive smoking | 1972 | 15.7 | Reference | |
| Dual use (cigarettes + ECs) | 510 | 25.4 | 1.97 (1.40 – 2.76) | |
| Exclusive vaping | 683 | 22.0 | 1.59 (1.11 – 2.29) | |
| Quit smoking and/or vaping | 1972 | 20.8 | 1.47 (1.04 – 2.07) | |
|
| ||||
| Current (other) smokeless tobacco use | <0.001 | |||
| No/not stated | 3664 | 18.1 | Reference | |
| Yes | 158 | 48.5 | 5.13 ( 2.82 – 9.33) | |
Data are weighted. 2022 and 2024 weighted data were pooled and a multivariable regression analysis was conducted. P-values, associated with the Wald F, represent the overall significance of each variable. aOR: adjusted odds ratio. CI: confidence interval. Smokeless tobacco use: snus, dip, chew, snuff. Time-in -sample (TIS) was not significant in the model (p=0.06). Ever used: ever tried an NP, even once.
Changes in current use of NPs among adults who currently or formerly smoked/vaped and current use
Between 2022 and 2024, the prevalence of current use of NPs increased by 66%, from 4.7% to 7.8% (p=0.007) (see Table 2). By each characteristic, there were significant increases in current use among males (6.3% to 10.3%, p=0.01), those aged 18–24 (1.2% to 15.0%, p=0.02) and 55+ (2.5% to 5.0%, p<0.01), those with high household income (5.7% to 9.9%, p=0.01), those with moderate education (4.7% to 8.7%, p=0.01), those who identified as White Non-Hispanic (4.6% to 8.0%, p=0.01), those who were exclusively smoking cigarettes (0.8% to 2.2%, p=0.03) or exclusively using ECs (2.0% to 8.1%, p=0.02), and those who were not currently using SLT products (3.3% to 6.5%, p<0.01).
Table 4 presents the pooled adjusted regression analyses comparing characteristics associated with current NP use. Current NP use was significantly higher among males (aOR=2.29, 95% CI: 1.28–4.10 vs. females), those who were dual using cigarettes and ECs (aOR=5.62 (3.18–9.93), exclusively vaping (aOR=2.90, 95% CI: 1.50–5.62), or quit smoking/vaping (aOR=7.43, 95% CI: 4.07–13.59) compared to those who were exclusively smoking, and those who were using SLT products (aOR=8.75, 95% CI: 4.37–17.55 vs. no current SLT use or not stated). There were no significant differences by age group, income, education, or race/ethnicity (all main effects tests were p≥0.05). We tested interactions between current use*characteristics and found a significant interaction by age (p=0.02) and smoking/vaping status (p=0.01). No other interactions were found (all p≥0.05).
Table 4:
Characteristics associated with current use of NPs among US adults who currently smoke cigarettes and/or vape nicotine or quit smoking and/or vaping
| Variables | n | % Current use | aOR (95% CI) | p-value main effect | p-value wave*predict or interaction |
|---|---|---|---|---|---|
| Wave | 0.002 | ||||
| Wave 4 (2022) | 1862 | 4.6 | Reference | — | |
| Wave 5 (2024) | 1864 | 7.8 | 2.02 (1.30 – 3.14) | ||
|
| |||||
| Sex | 0.005 | n.s | |||
| Female | 1838 | 7.4 | Reference | ||
| Male | 1888 | 3.8 | 2.29 (1.28 – 4.10) | ||
|
| |||||
| Age group | 0.12 | 0.02 | |||
| 18–24 | 105 | 7.7 | Reference | ||
| 25–39 | 869 | 7.4 | 0.95 (0.31 – 2.88) | ||
| 40–54 | 1011 | 5.8 | 0.69 (0.23 – 2.07) | ||
| 55+ | 1741 | 3.8 | 0.40 (0.12 – 1.31) | ||
|
| |||||
| Income | 0.07 | n.s | |||
| Low | 1104 | 3.3 | Reference | ||
| Moderate | 997 | 6.2 | 2.21 (0.95 – 5.17) | ||
| High | 1625 | 7.4 | 2.80 (1.16 – 6.75) | ||
|
| |||||
| Education | 0.29 | n.s | |||
| Low | 1334 | 5.2 | Reference | ||
| Moderate | 1504 | 7.1 | 1.50 (0.85 – 2.63) | ||
| High | 888 | 7.0 | 1.47 (0.78 – 2.78) | ||
|
| |||||
| Race/ethnicity | 0.99 | n.s | |||
| White Non-Hispanic | 2792 | 6.3 | Reference | ||
| Black Non-Hispanic | 403 | 6.4 | 1.02 (0.52 – 1.99) | ||
| Hispanic | 327 | 6.0 | 0.95 (0.37 – 2.41) | ||
| Other | 204 | 5.7 | 0.88 (0.29 – 2.71) | ||
|
| |||||
| Smoking/vaping status | <0.001 | 0.01 | |||
| Exclusive smoking | 1928 | 2.0 | Reference | ||
| Dual use (cigarettes + ECs) | 484 | 9.0 | 5.62 (3.18 – 9.93) | ||
| Exclusive vaping | 667 | 5.2 | 2.90 (1.50 – 5.62) | ||
| Quit smoking and/or vaping | 647 | 11.2 | 7.43 (4.07 – 13.59) | ||
|
| |||||
| Current (other) smokeless tobacco use | <0.001 | n.s | |||
| No/not stated | 3570 | 4.9 | Reference | ||
| Yes | 156 | 24.1 | 8.75 ( 4.37 – 17.55) | ||
Data are weighted. 2022 and 2024 weighted data were pooled and a multivariable regression analysis was conducted. Current use: at least monthly. aOR: adjusted odds ratio. CI: confidence interval. n.s: not significant. P-values, associated with the Wald F represent the main effect for each variable. aOR: Adjusted odds ratio. CI: confidence interval. The wave*predictor interactions were added to the main effect model to further test potential changes in effects over time. Other smokeless tobacco use: snus, dip, chew, snuff. TIS was not significant in the model (p=0.06).
We further tested the differences between 2022 and 2024 for current use of NPs by age and wave*age group interaction (Table 5). First, those aged 18–24 had the largest increase in current use (+13.8%, p=0.019) relative to those aged 25–39 (+1.8%, p=0.30), 40–54 (+1.6%, p=0.31) and 55+ (2.5%, p=0.005). When we compared the increase by wave between those aged 18–24 versus all other ages, we found significant differences between all age groups (p=0.045), where the changes between 2022 and 2024 were 11.8% greater than all other age groups combined.
Table 5.
Differences between 2022 and 2024 for current use of NPs by age and wave*age group interaction
| 2022 | 2024 | Difference between 2022 and 2024 | SE | t-statistic | p-value | |
|---|---|---|---|---|---|---|
| % (weighted) | ||||||
| Age group † | ||||||
| 18–24 | 1.2 | 15.0 | 13.8 | 0.059 | 2.34 | 0.019 |
| 25–39 | 6.7 | 8.5 | 1.8 | 0.017 | 1.04 | 0.30 |
| 40–54 | 5.0 | 6.6 | 1.6 | 0.015 | 1.02 | 0.31 |
| 55+ | 2.5 | 5.0 | 2.5 | 0.009 | 2.82 | 0.005 |
| Comparing 18–24 years vs. other age groups ± | ||||||
| 18–24 vs. 25–39 | — | — | 12.0 | 0.061 | 1.99 | 0.047 |
| 18–24 vs. 40–54 | — | — | 12.2 | 0.060 | 2.05 | 0.041 |
| 18–24 vs. 55+ | — | — | 11.3 | 0.060 | 1.91 | 0.056 |
| 18–24 vs. all age groups | — | — | 11.8 | 0.060 | 2.00 | 0.045 |
Data are weighted.
Percentages were estimated by predicted marginal effects in weighted logistic regressions incorporating generalized estimating equations (GEE), adjusting for age, sex, TIS and smoking/vaping status. Difference over time within each age group were tested by comparing the adjusted percentages. ±Difference over time between adults aged 18–24 vs. other age groups were further tested in the model by comparing the above within-group differences. NP: oral nicotine pouch. SE: standard error. Current NP use: at least monthly.
Supplemental Table 1 presents changes in NP use frequency among current NP users. Daily use of NPs doubled between 2022 and 2024 use (2.6% to 4.3%, p=0.048), with daily use most pronounced in those who were younger, and who reported having stopped smoking and/or vaping. There were non-significant increases in non-daily (2.3% to 3.6%, p= 0.14) and occasional (2.8% to 4.1%, p=0.17).
Supplemental Table 2 presents the pooled analysis of predictors of daily NP use compared to non-daily use. We found that daily use (vs. non-daily: weekly/monthly/occasional) was significantly higher among adults who reported that they quit smoking and/or vaping (aOR=10.69, 95% CI: 3.59–31.88). No other characteristics were significantly related to daily NP use; however, sample sizes may not have been large enough to detect differences.
DISCUSSION
Among US adults who smoke cigarettes and/or vape nicotine, or quit smoking and/or vaping, at least monthly use of NPs nearly doubled between 2022 and 2024, from 5% to 8% (with another 4% reporting using them occasionally), consistent with growth shown in US national sales data. There were significant increases in current NP use among those who were 18–24 and 55+ years of age, males, those with higher income, those who identified as Non-Hispanic White, those who exclusively smoked cigarettes or exclusively vaped ECs, and those not currently using other traditional SLTs (or did not answer). The prevalence of daily NP use also nearly doubled—from 2.6% to 4.3%—among this population of US adults with established cigarette and/or EC use.
In the pooled analyses, current NP use was significantly higher among males, those who reported using other SLT products, and those who quit smoking/vaping, were dual using ECs and cigarettes, or were exclusively vaping, which is consistent with other studies.11–16 Our findings suggest that there remains a large subset of adults who only smoke cigarettes and may be uninterested in trying non-combustible nicotine products. Adults who were using other nicotine products (ECs, SLT) appear to be more willing to try and continue to use NPs. We also found higher rates of NP use among those who were dual using ECs and cigarettes compared to those who were exclusively using ECs. Polytobacco use is prevalent among US adults;40–42 however, trends in using multiple nicotine products have been found to be transient.41,43 These changing use patterns are concerning because they may be associated with higher nicotine dependence and lower intentions to quit smoking,44,45 thus reasons for polyuse and transitions between products should be further explored in this rapidly changing nicotine market. We found that current NP use was highest among those who quit smoking and/or vaping, including daily NP use, which may indicate switching from cigarettes and/or ECs to exclusive NP use to help them stay quit. A more thorough examination of reasons for NP use among those who have quit using inhalable nicotine products should be explored, including among adults who have quit smoking and/or vaping for a period of time before initiating NP use.
The most pronounced increase in trying and using NPs was among adults ages 18–24. In 2022, 10% of adults in this age group had ever tried an NP, and by 2024, this has increased to 40%. Adults ages 55+ were the least likely to try NPs in both survey years, which is consistent with other findings in the US,16,40,46 and has also been observed in studies examining interest in ECs.47–50 Notably, while trying and/or experimentation with NPs increased among all adults (with the exception of those ages 25–39), the rate of current use was much lower. We are uncertain about the reasons why a large proportion of adults did not continue to use an NP after trying it, but its possible that many try NPs out of curiosity only, and/or found NPs less satisfying than smoking and/or vaping.
This study has some limitations. First, this study is descriptive in nature, thus, we do not attempt to imply causation (e.g., adults who formerly smoked successfully quit using an NP as a cessation aid). Second, although the respondents in this study were recruited from a probability-based commercial panel, initial response rates may have been low, thus warranting caution in interpreting the findings. Third, data were based on self-reported responses, which may be subject to recall bias or social desirability bias. Fourth, there was potential for misclassification of nicotine pouches, particularly given the evolving terminology and varying levels of familiarity with different nicotine products. This appeared to be more problematic in 2022, where some respondents indicated using nicotine replacement therapy or snus products; however, this appears to have been mostly mitigated in the 2024 survey, where a more extensive NP brand list was provided. Finally, the study sample did not include adults who have never smoked or vaped, limiting the generalizability of findings to the broader adult population and precluding comparisons with nicotine-naïve individuals.
CONCLUSION
Our findings indicate a significant increase in both ever and current use of NPs between 2022 and 2024 among adults with established nicotine product use. Increased use was more pronounced among adults aged 18–24 and those who quit smoking and vaping. To better understand the public health impact of NPs, future research should examine the extent to which adults who smoke and/or use ECs completely switch to NPs, and whether such switching contributes to sustained abstinence, especially among adults who smoke cigarettes. Moreover, the notably higher prevalence of NP use among those who report using other SLT products suggest that NP might be a substitute for traditional forms of oral tobacco.
Supplementary Material
WHAT IS ALREADY KNOWN ON THIS TOPIC.
Previous studies have documented the growing sales and emerging use of nicotine pouches (NPs) in the USA.
General US population studies show that the prevalence of NP use is low, with use being higher among adults with a history of nicotine use.
WHAT THIS STUDY ADDS.
This study is the first to report trends in use, and characteristics related to use of NPs among a nationally representative sample of US adults with established nicotine/tobacco product use.
Between 2022 and 2024, there were significant increases in ever, current, and daily use of NPs among US adults with established nicotine product use, most pronounced among younger adults and adults who have quit smoking and/or vaping.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY.
While findings suggest that use of NPs grew in adult populations that previously smoked cigarettes and/or vaped nicotine —and that this growth varies across subgroups—more research is needed to directly assess whether adults are using NPs to help them quit cigarette smoking, and to also better understand reasons for continuing or discounting use.
Funding:
The ITC Four Country Smoking and Vaping Survey was supported by grants from the US National Cancer Institute (P01 CA200512) and the Canadian Institutes of Health Research (FDN-148477). Additional support to GTF was provided by a Senior Investigator Grant from the Ontario Institute for Cancer Research (AI-004). This work was also supported in part by the National Cancer Institute and the US Food and Drug Administration (U01CA278695).
Footnotes
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or US Food and Drug Administration.
Declaration of competing interest: KMC has in the past and continues to serve as a paid witness in litigation filed against cigarette manufacturers. GTF has served as an expert witness or consultant for governments defending their country’s policies or regulations in litigation. All other authors declare no conflict of interest. All authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.
CRediT authorship contribution statement
Author credit: Conceptualization: SG, CD; Methodology: GM, SG; Formal analysis: GM; Writing - Original Draft: SG; Writing - Review & Editing: all authors; Visualization: all authors; Supervision: CD; Funding acquisition: GTF, KMC. All authors reviewed and approved the final version of the manuscript. SG and GM are the guarantors.
Data Availability Statement:
In each country participating in the International Tobacco Control Policy Evaluation (ITC) Project, the data are jointly owned by the lead researcher(s) in that country and the ITC Project at the University of Waterloo. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
In each country participating in the International Tobacco Control Policy Evaluation (ITC) Project, the data are jointly owned by the lead researcher(s) in that country and the ITC Project at the University of Waterloo. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org).