Abstract
Introduction
Evidence on the association between tobacco/nicotine and other substance use (TOSU) and adolescent nicotine pouch (NP) awareness and use is lacking but vital for policy and prevention planning.
Methods
The sample was drawn from the 2023 Monitoring the Future study, a nationally representative survey of U.S. adolescents (8th, 10th, 12th graders). One-third of participants were randomly selected to complete questions on NP awareness and use (lifetime, past 12-month, past 12-month frequency) and past 30-day TOSU measures (yes/no). We estimated risk ratios (RRs) and incident rate ratios (IRRs) to examine the associations between TOSU and NP awareness and use.
Results
Overall (n=6,958; 53.4% female), 35.4% reported NP awareness, 2.5% reported lifetime use, and 1.8% reported past 12-month use. Past 30-day use of tobacco/nicotine products was each positively associated with NP awareness (RRs:1.42–1.70), lifetime (RRs:7.14–20.40), and past 12-month (RRs:5.84–22.44) use, with the strong associations for youth with vs. without smokeless tobacco use. Cannabis, alcohol, and other drug past 30-day use were each associated with NP awareness (RRs:1.49–1.68), lifetime (RRs:3.47–10.49), and past 12-month (RRs:4.70–15.70) use.
Conclusions
NP awareness and use prevalence were disproportionately high among adolescents with various forms of TOSU in 2023, especially smokeless tobacco. These findings suggest the importance of monitoring NP use among youth with TOSU while recognizing that awareness may also reflect broader marketing, product availability, or incidental exposure. Policy and prevention efforts should address NP use alongside TOSU with established health risks.
Keywords: nicotine pouch, awareness, use prevalence, tobacco/substance use correlates, adolescents
INTRODUCTION
Nicotine pouches (NP, i.e., sachets containing microcrystalline cellulose, nicotine, flavorings, and other additives, which contain no tobacco leaf) are increasingly marketed in the US.1 During 2016–2020, U.S. dollar sales of NPs increased by 305%.1 NPs might appeal to youth because they can be used discreetly and come in a wide availability of flavors.1,2 Although NPs lack certain toxins present in combustible tobacco smoke, they still deliver significant amounts of nicotine to the blood stream through buccal absorption,3 and may possess substantial addiction potential. Given that nicotine exposure during adolescence may interfere with optimal neurocognitive development4 and potentially increase risk of depression,5 understanding factors implicated in adolescent NP use is important.
A recent review found that 35–42% of adolescents and young adults had heard of NPs through 20236 and 2.3% of US middle and high school students reported NP ever use in 2023.7 The increased awareness may be due to marketing influences and the positioning of NPs as a viable and practical alternative for nicotine intake.8,9 Awareness and use of NPs may be substantially higher in youth who use other tobacco/nicotine products due to the perception that NPs can be used in places where inhaled products (e.g., e-cigarettes) or traditional smokeless tobacco (e.g., chewing tobacco, snuff, plug, dipping tobacco, snus) are prohibited or difficult to conceal. The only published study based on nationally representative data that examined youth NP awareness used the 2021 National Youth Tobacco Survey,10 which showed that NP awareness was more prevalent among adolescents who currently use smokeless tobacco (64.5%), followed by cigarettes (53.0%), e-cigarettes (51.6%), heated tobacco products (50.7%), and cigars (47.6%) relative to the general population (35.5%).10 Similarly, ever NP use was prevalent among adolescents who currently use smokeless tobacco (50.5%), cigarettes (18.4%), or e-cigarettes (14.8%) relative to the general population (1.9%).10 Adolescents with tobacco/nicotine and other substance use (TOSU) may be more likely to use NPs due to shared risk factors (e.g., sensation-seeking, peer influence) and common liability.11–13 Little is known about how TOSU is associated with NP use.
This cross-sectional investigation used data from the 2023 Monitoring the Future (MTF) survey,14 a nationally representative survey of U.S. adolescents, to examine the association of TOSU with NP awareness and use prevalence. Documenting these associations can inform prevention efforts by identifying which groups of adolescents are at risk for NP use and guiding targeted interventions.
METHODS
Participants and Procedures
The MTF study is a nationally-representative study that administers cross-sectional classroom-based surveys of 8th-, 10th-, and 12th-grade students.14 This ongoing study selects schools using a multistage random sampling design and collects information about health behaviors and beliefs. Passive (letter sent to parents/caregivers) or active (written) informed consent was obtained, per school policy, from parents of participants younger than 18 years or from participants aged ≥18 years. This study used data from surveys administered during February-June 2023. We analyzed participants who were randomly assigned survey forms that included questions on NP and TOSU, which were given to one-third of the total sample. Of the 7,430 students who completed the subforms, the analytic sample was restricted to adolescents with non-missing data on NP use (N=6,958).
Measures
TOSU variables.
Four separate tobacco/nicotine product use variables were cigarettes, e-cigarettes with nicotine, smokeless tobacco, and cigars/hookah (e.g., large cigars, flavored/regular little cigars/cigarillos, hookah). A composite variable of any tobacco/nicotine product use was also created (use of ≥1 vs. 0 of the preceding 4 tobacco/nicotine product classes [cigarettes, e-cigarettes, smokeless tobacco, cigars/hookah]). Four separate non-tobacco/nicotine substance variables were cannabis smoking, cannabis vaping, alcohol, or any other drugs (i.e., prescription drug misuse, including stimulants, sedatives, and tranquilizers, and illicit drugs such as cocaine, crystal meth, and heroin). Similarly, a composite variable of any non-tobacco/nicotine substance was also created (use of ≥1 vs. 0 non-tobacco/nicotine substances [cannabis smoking, cannabis vaping, alcohol, other drugs]). Each of these was coded as a binary variable: 0 vs. 1+ days/occasions in the past 30 days (i.e., current use).
Outcome variables.
NP awareness was assessed with a single survey item in the data: “Have you ever seen/heard of nicotine pouches before now?” (yes/no). Participants reported their NP use based on two separate questions about how many occasions they had used NPs in their lifetime and during the past 12 months, with response options of 0, 1–2, 3–5, 6–9, 10–19, 20–39, and 40+ occasions. Responses for the lifetime and past-12-month use variables were each recoded into two separate dichotomous variables (0 vs. 1+ occasions). This study did not include past-30-day NP use outcomes due to small cell sizes for most correlates.
Covariates.
Sociodemographic factors that have been previously associated with use of NPs14–16 were included as covariates, including grade, sex, race/ethnicity, urbanicity, and plan to attend a four-year college.
Statistical Analysis
We estimated the prevalence of NP awareness and use outcomes stratified by each correlate variable. Rao-Scott Chi-squared tests17 and independent samples t-tests respectively assessed differences in the prevalence of dichotomous and count outcomes by correlate variables. We fitted separate log-binomial models that included one TOSU correlate at a time, controlling for sociodemographic covariates. This approach avoided potential multicollinearity across the multiple TOSU variables. As NP use correlates might vary across developmental stages, supplemental TOSU variables×grade interactions were tested. Missing data on correlate variables and covariates (tobacco/nicotine use: ~1.0%, non-tobacco/nicotine substance use: ~2.7%, sociodemographic factors: ~2.9%, sociodemographics: ~15.0%) were handled using multiple imputation with chained equations.18 We conducted sensitivity analyses by repeating the primary analyses using complete-case data. In this descriptive epidemiologic study, significance was set to 0.05 (two-tailed; uncorrected for multiple tests given the study’s exploratory approach). We applied the cross-sectional weights provided by the MTF to ensure nationally representative estimates. Analyses used R version 4.2.1.
RESULTS
The analytic sample (N=6958; 8th grade n=1983[28.8%], 10th=2648[40.0%], 12th=2327[31.2%]) included 47.4% female and 44.7% Non-Hispanic White (Supplemental Table 1) students. Overall, 35.4% of participants reported awareness of NPs, and 2.5% and 1.8% reported lifetime and past 12-month use, respectively. Among TOSU, e-cigarettes (11.5%) and alcohol (14.1%) were the most commonly used substances (see Table 1). Participants excluded due to missing outcome data differed somewhat from those retained, being more likely male, Hispanic/Latino, less academically oriented, and higher in substance use (Supplemental Table 2).
Table 1.
Nicotine Pouch Awareness and Use Prevalence by Tobacco and Other Substance Use (N = 6958)
| Nicotine pouch outcome | ||||
|---|---|---|---|---|
| Overall sample, % (95%CI)a |
Awareness, % (95%CI)b |
Lifetime use, % (95%CI)b |
Past 12-month use, % (95%CI)b |
|
| Past 30-day tobacco/nicotine use | ||||
| Cigarette use | ||||
| No | 98.2 (97.6–98.6) | 35.0 (32.2–37.9) | 2.1 (1.7–2.7) | 1.6 (1.2–2.1) |
| Yes | 1.8 (1.4–2.4) | 56.0 (44.6–66.8)* | 23.4 (15.7–33.5)* | 15.2 (9.4–23.7)* |
| E-cigarette use | ||||
| No | 88.5 (87.2–89.7) | 32.9 (30.3–35.7) | 0.9 (0.6–1.3) | 0.5 (0.3–0.7) |
| Yes | 11.5 (10.3–12.8) | 54.6 (48.9–60.2)* | 14.6 (11.6–18.1)* | 12.2 (9.4–15.7)* |
| Smokeless tobacco usec | ||||
| No | 98.9 (98.5–99.2) | 35.0 (32.2–37.9) | 1.8 (1.4–2.3) | 1.3 (0.9–1.7) |
| Yes | 1.1 (0.8–1.5) | 73.2 (56.0–85.4)* | 61.9 (46.0–75.6)* | 54.6 (39.7–68.2)* |
| Cigars/hookah used | ||||
| No | 97.5 (96.8–98.0) | 34.7 (31.9–37.7) | 1.9 (1.5–2.5) | 1.3 (1.0–1.8) |
| Yes | 2.5 (2.0–3.2) | 58.6 (47.5–68.8)* | 23.0 (14.7–34.1)* | 20.8 (12.8–32.1)* |
| Any tobacco/nicotine usee | ||||
| No | 86.5 (85.1–87.8) | 32.5 (29.8–35.2) | 0.6 (0.4–0.9) | 0.4 (0.2–0.6) |
| Yes | 13.5 (12.2–14.9) | 53.8 (48.5–58.9)* | 14.5 (11.6–18.1)* | 11.2 (8.6–14.4)* |
| Past 30-day non-tobacco/nicotine substance use | ||||
| Cannabis smoking | ||||
| No | 89.4 (87.7–90.9) | 33.1 (30.5–35.8) | 1.5 (1.1–2.1) | 1.0 (0.7–1.4) |
| Yes | 10.6 (9.1–12.3) | 54.0 (48.1–59.8)* | 10.5 (7.8–13.9)* | 9.1 (6.6–12.4)* |
| Cannabis vaping | ||||
| No | 92.2 (91.1–93.2) | 33.6 (31.0–36.4) | 1.6 (1.2–2.2) | 1.1 (0.8–1.5) |
| Yes | 7.8 (6.8–8.9) | 56.0 (49.3–62.5)* | 12.8 (9.6–17.0)* | 10.7 (7.6–14.8)* |
| Alcohol use | ||||
| No | 85.9 (83.8–87.8) | 31.6 (29.2–34.2) | 1.0 (0.7–1.5) | 0.6 (0.4–0.9) |
| Yes | 14.1 (12.2–16.2) | 58.1 (52.7–63.3)* | 11.4 (8.5–15.0)* | 9.6 (0.7–13.1)* |
| Other drug usef | ||||
| No | 97.1 (96.4–97.6) | 35.1 (32.3–38.1) | 2.3 (1.8–2.9) | 1.7 (1.2–2.2) |
| Yes | 2.9 (2.4–3.6) | 49.7 (40.5–59.0)* | 8.6 (4.9–14.7)* | 8.4 (4.7–14.5)* |
| Any non-tobacco/nicotine substance useg | ||||
| No | 77.6 (74.9–80.0) | 30.3 (27.9–32.7) | 0.7 (0.5–1.2) | 0.4 (0.2–0.6) |
| Yes | 22.4 (20.0–25.1) | 53.9 (49.0–58.1)* | 8.8 (6.9–11.0)* | 7.2 (5.5–9.4)* |
Note. Awareness indicates reported having ever seen or heard of nicotine pouches before the survey. SD = standard deviation, M = mean, CI = confidence interval.
Weighted % (95% CI) in overall sample (column percent).
Weighted % who have positive status for each nicotine pouch prevalence outcome (stratified by tobacco or other substance use variable status (row percent).
Chewing tobacco, snuff, plug, dipping tobacco, snus.
Large cigars, flavored little cigars/cigarillos, regular little cigars/cigarillos, or tobacco using a hookah.
Cigarettes, e-cigarettes, smokeless tobacco, or cigars/hookah.
A LSD, hallucinogens other than LSD, cocaine, crystal meth, heroin, crack, or methamphetamine or prescription stimulant drugs, sedatives, tranquilizers, or other narcotics.
Cannabis smoking, cannabis vaping, alcohol use, or other drug use.
Statistically significant (<0.05) difference relative to those who did not use the tobacco product or other substance using the weighted Pearson Chi-Squared test with Rao-Scott adjustment or weighted independent samples t-test (for count outcome).
Table 1 presents NP use prevalence, stratified by TOSU correlate. Table 2 presents estimates of associations between past 30-day TOSU and NP awareness and use outcomes. Past 30-day use of cigarettes, e-cigarettes, smokeless tobacco, cigars/hookah, or any tobacco/nicotine product was associated with higher NP awareness (53.8%−73.2% among those who used tobacco/nicotine products: vs. 32.5%−35.0% among those with no use of any tobacco/nicotine products; risk ratio[RR] range:1.42–1.53), lifetime use (14.5%−61.9% vs. 0.6%−2.1%; RR range: 7.14–20.40), and past 12-month use (11.2%−54.6% vs. 0.4%−1.6%; RR range: 5.84–22.44). Those who smoked or vaped cannabis, used alcohol, other drugs, or any non-tobacco/nicotine substances were more likely than non-using counterparts to report NP awareness (49.7%−58.1% vs. 30.3%−35.1%; RR range: 1.49–1.68) and use (lifetime use: 8.6%−12.8% vs. 0.7%−2.3%, RR range: 5.14–10.49; past-12-month use: 7.2%−10.7% vs. 0.4%−1.7%, RR range: 4.70–15.70).
Table 2.
Tobacco and Other Substance Use Correlates of Nicotine Pouch Awareness and Use, 2023 (N = 6958)
| Nicotine pouch outcome | ||||||
|---|---|---|---|---|---|---|
| Awarenessa | Lifetime use | Past 12-month use | ||||
| RR | 95% CI | RR | 95% CI | RR | 95% CI | |
| Past 30-day tobacco/nicotine use | ||||||
| Cigarettes | 1.42 | 1.19 – 1.70 | 7.14 | 4.15 – 12.28 | 5.84 | 3.42 – 9.95 |
| E-cigarettes | 1.52 | 1.37 – 1.69 | 13.24 | 9.16 – 19.15 | 19.55 | 12.16 – 31.43 |
| Smokeless tobaccob | 1.70 | 1.42 – 2.04 | 16.57 | 11.70 – 23.47 | 21.45 | 14.29 – 32.19 |
| Cigars/hookah productsc | 1.52 | 1.31 – 1.78 | 7.74 | 4.68 – 11.92 | 9.39 | 5.67 – 15.57 |
| Any tobacco/nicotine productd | 1.53 | 1.40 – 1.67 | 20.40 | 12.97 – 32.09 | 22.44 | 13.57 – 37.09 |
| Past 30-day non tobacco/nicotine substance use | ||||||
| Cannabis smoking | 1.49 | 1.37 – 1.63 | 5.14 | 3.38 – 7.83 | 6.39 | 3.71 – 10.99 |
| Cannabis vaping | 1.50 | 1.35 – 1.67 | 6.05 | 3.98 – 9.21 | 6.88 | 4.27 – 11.08 |
| Alcohol | 1.68 | 1.54 – 1.83 | 9.29 | 5.70 – 15.15 | 12.66 | 7.42 – 21.61 |
| Drug usee | 1.41 | 1.19 – 1.67 | 3.47 | 1.93 – 6.23 | 4.70 | 2.41 – 9.16 |
| Any non-tobacco/nicotine substance usef | 1.68 | 1.56 – 1.82 | 10.49 | 6.24 – 17.62 | 15.70 | 8.93 – 27.61 |
Note. Each estimate adjusted for sociodemographic characteristics in Supplemental Table 1. RR = risk ratio; IRR = incidence rate ratio; CI = confidence interval.
Reported having ever seen or heard of nicotine pouches before the survey.
Chewing tobacco, snuff, plug, dipping tobacco, snus.
Large cigars, flavored little cigars/cigarillos, regular little cigars/cigarillos, or tobacco using a hookah.
Cigarettes, e-cigarettes, smokeless tobacco, or cigars/hookah.
A LSD, hallucinogens other than LSD, cocaine, crystal meth, heroin, crack, or methamphetamine or prescription stimulant drugs, sedatives, tranquilizers, or other narcotics.
Cannabis smoking, cannabis vaping, alcohol use, prescription, or other drug use.
Sensitivity analyses restricted to complete cases produced results largely consistent with the main analyses (Supplemental Table 3). Supplemental analyses of grade×TOSU interactions were generally non-significant (Supplemental Table 4), with two exceptions: the associations (RRs) of past 12-month NP use with past 30-day cannabis smoking and cannabis vaping were stronger among 8th- and 10th-graders compared to 12th-graders (Supplemental Table 5). Sociodemographic correlates of NP awareness and use are presented in Supplemental Table 6 and are largely consistent with recent findings of adolescents.19
DISCUSSION
This cross-sectional analysis described patterns of NP awareness and use among nationally representative U.S. adolescents in 2023 and examined how these patterns differed by TOSU status. NP awareness was moderately elevated in youth with TOSU but still appreciable among youth without TOSU. By contrast, the difference in NP use by TOSU status was substantial, with NP use base levels being low in youth without TOSU. Given the recent increase in NP marketing and the relatively new presence of these products in the market, use appears to be concentrated among early adopters.20,21 Awareness may be the first stage of the emerging product adoption process, followed by interest, evaluation, trial, and adoption.22 This framework, supported by prior studies of e-cigarette diffusion in young populations,23,24 might provide context for how NPs may follow similar adoption trajectories. Ongoing surveillance of NP awareness and use among adolescents will be critical to characterize evolving adoption trajectories and to guide evidence-based regulatory and prevention strategies.
Awareness and use of NPs were higher among adolescents with TOSU, suggesting a broader vulnerability to substance involvement rather than a distinct risk category specific to NP use. This pattern may reflect shared psychosocial and environmental factors that increase susceptibility to multiple forms of substance use.25 Additional risk factors may include peer influence, exposure to media and marketing, neurobiological sensitivity to nicotine and related cues, and familiarity with oral nicotine product use.26 These findings indicate that comprehensive prevention strategies addressing common risk and protective factors, (e.g., curiosity, sensation seeking, perceived harm) across multiple substance types may be more effective than approaches that focus narrowly on a single product category.
Smokeless tobacco use was a robust TOSU correlate of NP use. These products share an oral route of administration and similar use topography, and adolescents who use NPs may be inclined to use other oral nicotine products such as smokeless tobacco. They also appear to target overlapping demographic groups (e.g., male, White, rural, lower education),19 which may contribute to the observed co-use. In addition, in our supplemental analyses, we found stronger cannabis-NP associations among 8th and 10th (vs. 12th) graders, suggesting that polysubstance use patterns involving NPs may emerge earlier in adolescence. Future studies should evaluate the mechanisms underlying the co-use of smokeless tobacco, cannabis, and NPs.
It is also worth noting that although national sales of NPs have risen in recent years,1,21 these sales data primarily reflect adult markets and may not correspond directly to adolescent uptake. Our findings indicate that adolescent awareness and use have remained relatively stable between 2021 and 2023.2,7,10 This discrepancy may suggest that the rapid increase in NP sales might have been driven primarily by adult consumers with uptake among adolescents progressing at a slower pace.
A study limitation is that lifetime and past 12-month use of certain tobacco/nicotine products and substances were not available, necessitating focus on past 30-day TOSU. Also, given small cell sizes, past 30-day NP use outcomes were not examined due to imprecise estimates. NP awareness was measured with a single item, without follow-up questions, limiting the assessment of depth or accuracy. The cross-sectional design precludes establishing temporal ordering between TOSU and NP awareness or use – it remains unclear whether TOSU typically precedes NP use or whether some adolescents initiate with NPs. Therefore, caution is warranted when interpreting these findings as evidence of increased vulnerability or prioritization among youth with TOSU. Additionally, our analytic sample was limited to adolescents, thereby avoiding extrapolation to adult populations. Finally, exclusion due to missing outcome data may limit generalizability and introduce bias.
This study provides new evidence that awareness and use prevalence of NPs were high among adolescents with TOSU. Higher awareness and use of NPs among adolescents with TOSU may indicate a broader susceptibility to substance involvement rather than a unique risk specific to NP use. Addressing shared risk factors that contribute to multiple forms of substance use, including openness to novel nicotine products, may enhance the effectiveness of adolescent prevention strategies. Future mediation studies should identify and test specific pathways linking TOSU and NP use (e.g., social influence, product accessibility) to demonstrate how these factors contribute to co-use patterns. Longitudinal designs with repeated measures are warranted to examine temporal associations between TOSU and NP.
Supplementary Material
Highlights.
Adolescent nicotine pouch use was linked to tobacco and other substance use behaviors.
Smokeless tobacco use was strongly associated with nicotine pouch use.
Findings support integrated prevention addressing pouches alongside other substances.
Acknowledgements
Research was supported by the National Cancer Institute and Food and Drug Administration under Award Numbers U54180905 and National Institute on Drug Abuse under Award Numbers R01DA001411, K01DA058084, K24DA048160, and K99DA058241. The funders had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.
Footnotes
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Declaration of Interest Statement:
No conflict declared.
Conflict of Interest
The authors have no conflicts of interest relevant to this article to disclose.
Declaration of generative AI and AI-assisted technologies in the manuscript preparation process: During the preparation of this work, the authors used ChatGPT in order to detect and correct grammatical errors. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
Data availability statement
Data are available in a public, open-access repository, the National Addiction & HIV Data Archive Program (NAHDAP): https://www.icpsr.umich.edu/web/NAHDAP/studies/39172
Data Availability Statement
The data underlying this article will be shared at reasonable request to the corresponding author.
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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
Data are available in a public, open-access repository, the National Addiction & HIV Data Archive Program (NAHDAP): https://www.icpsr.umich.edu/web/NAHDAP/studies/39172
The data underlying this article will be shared at reasonable request to the corresponding author.