Abstract
Introduction:
Nicotine pouch sales have substantially increased in the US. We examined the patterns of dually using nicotine pouches with other tobacco products, and whether nicotine pouch use was associated with tobacco product use cessation.
Methods:
A nationally representative sample of US adults (≥21 years) participated in an online survey in 2024 and provided information about their tobacco use behaviors in 2023 and 2024, along with demographics. This analysis was restricted to those who reported using any tobacco products in 2023 (n=1,460). Data were weighted to be nationally representative. Predictive marginal probability differences (PMPD) were used to examine the association between nicotine pouch use in 2023 and tobacco product use cessation in 2024.
Results:
In 2023, 12.0% of US adults who used tobacco products reported currently using nicotine pouches with another tobacco product. Among those who used nicotine pouches dually with at least one other tobacco product in 2023, none switched to exclusive nicotine pouch use in 2024, and 47.1% continued dual-use, 10.1% stopped using all tobacco products, and 42.8% stopped using nicotine pouches in 2024. US adults who dual-used nicotine pouches with other tobacco products in 2023 had lower probabilities than those who did not dual-use to quit tobacco product use in 2024 (10.1% vs. 23.7%; PMPD=−15.2%, 95% CI=−20.8%, −9.6%).
Conclusions:
Among US adults who dually used nicotine pouches with other tobacco products, none completely switched to exclusive nicotine pouch uses. Nicotine pouch use was also not associated with increased probabilities of quitting tobacco product use.
INTRODUCTION
Nicotine pouches are relatively novel commercial nicotine products being sold worldwide.[1] They are small bags made from a permeable material, containing a cellulose matrix of polymer fibers mixed with nicotine salt, water, and other constituents, including sweeteners, or flavors.[1] They are different from snus, which contains grounded moist snuff tobacco in small permeable bags.[1] Sales and use of nicotine pouches have increased globally since its introduction. For example, between August to December of 2019 and January to March of 2022, sales of nicotine pouches in the US increased by six-fold, from 126.06 million units to 808.14 million.[2] In 2022, 7.3 million (2.9%) US adults reported ever using nicotine pouches, while 0.9 million (0.4%) reported using them at least some days.[3] Furthermore, almost half of U.S. adults who use commercial tobacco have reported being aware of nicotine pouches through various marketing channels, and awareness of nicotine-pouch marketing has been associated with higher likelihood of nicotine pouch experimentation.[4] Similarly, while uncommon, prevalence of nicotine pouch use more than doubled from 0.14% to 0.32% in the UK from November 2020 to October 2021.[5] In both countries, younger male adults were more likely to report current nicotine pouch use than older female adults.[3, 5] Young adults in Australia also expressed in early 2024 an overall positive perception of nicotine pouches and agreed that they were increasingly popular as part of the partying culture.[6]
A recent review suggested, based on limited research of nicotine pouches on health impact, that while nicotine pouches are not risk-free, they may likely pose less harm to those who use them than conventional tobacco products (e.g., cigarettes or moist snuff).[7] Biomarker analysis of US adults participating in the Population Assessment of Tobacco and Health Study found that compared to adult who only smoked cigarettes, those who only use nicotine pouches had lower exposure to tobacco alkaloids (e.g., anabasine and anatabine) and lead.[8] Given the ability of nicotine pouches to deliver high levels of nicotine, hence easing nicotine withdrawal symptoms, it is possible that completely switching from conventional tobacco products to nicotine pouches may reduce harm to those who use them.[7] However, analysis of nicotine pouches also found levels of freebase nicotine comparable to smokeless moist snuff, which could contribute to nicotine addiction and related health consequences.[9] Studies have also reported oral mucosa and microbe changes and lesions associated with nicotine pouch use.[10–12]
While randomized clinical trials may provide information on whether nicotine pouches can provide tobacco product use cessation, population-based studies provide important information on whether nicotine pouches are being used for tobacco product use cessation in real-world settings. For example, multiple randomized clinical trials found that providing free electronic vaping products (e.g., e-cigarettes) was associated with smoking cessation, while other clinical trials found no associations. [13] Meanwhile, multiple population-based studies showed that electronic vaping product use as a consumer product was associated with lower likelihood of smoking cessation, others found no associations, and a few reported found higher likelihood of smoking cessation especially with daily electronic vaping product use. [13] Instead, dual use of e-cigarettes and cigarettes became more prevalent over time both in the US and the UK.[14, 15] To date, limited number of studies have examined the prevalence of dually using nicotine pouches and other tobacco products among adults, and whether nicotine pouch use is associated with tobacco product use cessation. Data from the 2023–2023 US Tobacco Use Supplement to the Current Population Survey showed that 1–2% of adults who smoked daily or non-daily reported also using nicotine pouches. [16, 17] Therefore, we conducted a retrospective analysis to (1) estimate the prevalence of dually using nicotine pouches with other tobacco products, (2) investigate patterns of tobacco product use behaviors over time among those who dually use nicotine pouches with other tobacco products, and (3) examine the relationship between nicotine pouch use and tobacco product use cessation among US adults.
METHODS
Study population
Data for this analysis came from the CANDLE Study, a US nationally representative cross-sectional study.[18] The CANDLE study was conducted with a national sample of US adults selected from the YouGov online panel between March and May 2024. The inclusion criteria included (1) residing in the US and (2) being 21 years of age or older (i.e., legal age to purchase tobacco products). The study oversampled adults who use commercial tobacco, as well as American Indian/Alaska Native, Asian, Black/African American, and Hispanic/Latino adults. To achieve national representation, YouGov uses a sample matching approach. Briefly, YouGov used data from nationally representative surveys to draw a sample of individuals who met the inclusion criteria of the study. A sample of YouGov panelists with matching demographics and commercial tobacco use experiences, were invited to participate in the study through emails. This sampling approach has been demonstrated to achieve source-population representation as in random-digit-dialing sampling after statistical weighting.[19, 20] They provided informed consent before completing the survey and were compensated according to YouGov policy. Panelists who provided inconsistent responses were excluded from the study, resulting in a predetermined sample size of 3,200 (response rate=73.5%). National Institutes of Health Institutional Review Board (IRB) reviewed this study and determined it to be exempt from IRB review per 45 CFR 46. Panelists who met the inclusion criteria were invited to participate in the study. In this analysis, individuals who reported using cigarettes, electronic vaping products, cigars (including litter cigars and cigarillos), hookah, heated tobacco products (e.g., IQOS), other combustible tobacco products (e.g., pipes, roll-your-own cigarettes), and smokeless tobacco (e.g., chewing tobacco, snuff) some days or every day 12 months prior to the survey were included to retrospectively reconstruct a cohort of adults who use commercial tobacco during March to May of 2023 (n=1,460).
Measures
Nicotine pouch use.
To assess nicotine pouch use in 2023 and 2024, two items were used. First, participants were asked “Have you used the nicotine pouches, which are microfiber pouches with flavored nicotine powder that users dissolve in the mouth without spitting (e.g., ZYN, On!, Velo)?” Response options were “never”, “used before but not now”, “currently using it some days”, “currently using it every day”. Participants who responded used before but not now or currently using it some days or every day were then asked, “Think about your tobacco use this time 12 months ago, [reference month and year provided], how often did you use nicotine pouches?” Response options were “used before 2023 but not during that month”, “some days”, “every day”. Current nicotine pouch use in 2023 was defined as reporting using nicotine pouches “some days” or “every day” in 2023, while no current nicotine pouch use in 2023 was defined as reporting “never” used nicotine pouches in 2024 or “used before 2023 but not during that month” in 2023. Current nicotine pouch use in 2024 was defined as reporting using nicotine pouches “some days” or “every day” in 2024, while no current nicotine pouch use in 2024 was defined as reporting “never” used nicotine pouches in 2024 or “used before but not now” in 2024.
Dually using nicotine pouches with other tobacco products in 2023.
Participants reported use of various tobacco products in 2023, including cigarettes, electronic vaping products, cigars, hookah, heated tobacco products, other combustible tobacco products, and smokeless tobacco products. Those who reported using a product some days or every day were classified as currently using that product (vs. participants who reported not using that product in 2023). Responses were used to categorize whether participants currently dually using nicotine pouches with at least one other tobacco product (i.e., current use of nicotine pouches and current use of any other tobacco products), and currently dually using nicotine pouches with a specific tobacco product (e.g., currently use of nicotine pouches and current use of cigarettes).
Outcome: Pattern of tobacco products use and cessation.
Participants reported whether they currently used various tobacco products (i.e., some days or every day) or not in 2024, including cigarettes, electronic vaping products, cigars, hookah, heated tobacco products, other combustible tobacco products, smokeless tobacco products, and nicotine pouches. We then ascertained, among those who reported dual using nicotine pouches and another tobacco product, if they switched completely to nicotine pouches, continued dual use, stopped using both products, or stopped using nicotine pouches. For example, among those who dual used nicotine pouches and cigarettes in 2023, completely switching to nicotine pouches was defined as currently using nicotine pouches but not cigarettes; continued dual use was defined as currently using nicotine pouches and cigarettes; stopping use of both products was defined as not currently using nicotine pouches or cigarettes; and stopping use of nicotine pouches was defined as not currently using nicotine pouches but currently using cigarettes. Finally, participants who reported current use of a tobacco product in 2023 but not in 2024 were classified as having quit using the product. For example, participants were categorized as quitting cigarette smoking if they reported current cigarette smoking in 2023 but not in 2024.
Covariates.
Demographics including age, sex, race and/or ethnicity, education, and annual household income were collected. Participants were categorized into American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, White, or other (including Native Hawaiian or Pacific Islander, Middle Eastern or North African, mixed races and/or ethnicity, and other race and/or ethnicity because of the small number of participants in each of these groups). Annual household income was dichotomized at US$75,000 to align with US median household income at the time of survey. We were unable to adjust for nicotine dependence in 2023 because that information was not ascertained.
Statistical analysis
Data were weighted to be nationally representative. We first estimated the prevalence of dual nicotine pouch use among participants who currently used any tobacco products, as well as specific tobacco products in 2023. We then estimated the prevalence of switched completely to nicotine pouches, continued dual use, stopped using both products, or stopped using nicotine pouches between 2023 and 2024 among those who dual used nicotine pouches with another tobacco product. Next, we examined the prevalence of tobacco product use cessation in 2024 by current nicotine pouch use status in 2023. Finally, weighted multivariate logistic regression models were used to estimate the predictive marginal probabilities of tobacco product use cessation in 2024 among those who did or did not use nicotine pouches in 2023, adjusting for demographics. Predictive marginal probability differences were then used to assess whether those who used nicotine pouches in 2023 had a different probability of tobacco product use cessation in 2024 compared to those who did not use nicotine pouches in 2023. All analyses were conducted in SAS® version 9.4 (SAS Institute: Cary, NC).
RESULTS
Table 1 shows the demographic characteristics of US adults who currently used tobacco products in 2023 overall and by tobacco products. Overall, about two-thirds of them were White, a third were 31–45 years old, three-fifths were male, two-thirds had annual household income less than US$75,000, and almost half had a high school education or less. These characteristics varied slightly across US adults who used different tobacco products.
Table 1.
Demographic characteristics of US adults who reported current tobacco product use in 2023.
| Tobacco product used in 2023 | ||||||||
|---|---|---|---|---|---|---|---|---|
| Characteristic | Any (n=1460) | Cigarette (n=1116) | Electronic vaping products (n=611) | Cigars (n=478) | Hookah (n=226) | Heated tobacco products (n=155) | Other combustibles (n=326) | Smokeless tobacco products (n=267) |
|
| ||||||||
| Race and/or ethnicity | Weighted % | Weighted % | Weighted % | Weighted % | Weighted % | Weighted % | Weighted % | Weighted % |
| AIAN | 1.0% | 1.0% | 1.2% | 1.0% | 0.8% | 0.8% | 1.0% | 1.0% |
| Asian | 3.0% | 2.9% | 3.1% | 2.1% | 4.9% | 4.7% | 1.7% | 3.4% |
| Black/African American | 12.0% | 12.0% | 9.9% | 16.7% | 16.6% | 14.0% | 11.7% | 16.0% |
| Hispanic/Latino | 16.9% | 15.9% | 19.2% | 17.7% | 21.6% | 15.5% | 17.5% | 19.2% |
| Other | 1.4% | 1.2% | 17.0% | 2.2% | 2.5% | 0.6% | 1.6% | 1.0% |
| White | 65.7% | 67.0% | 64.8% | 60.3% | 53.6% | 64.5% | 66.4% | 59.4% |
| Age (year) | ||||||||
| 18–30 | 22.6% | 21.7% | 26.6% | 26.6% | 33.3% | 31.8% | 30.9% | 37.8% |
| 31–45 | 36.2% | 36.6% | 46.4% | 44.0% | 51.1% | 59.6% | 40.3% | 40.1% |
| 46–60 | 23.8% | 23.2% | 17.8% | 18.5% | 14.2% | 5.6% | 18.9% | 18.0% |
| 61 and older | 17.4% | 18.5% | 9.2% | 10.9% | 1.4% | 3.0% | 9.9% | 4.1% |
| Sex | ||||||||
| Unknown | 1.0% | 1.0% | 0.9% | 0.6% | 0.4% | 0.3% | 1.6% | 1.5% |
| Female | 39.1% | 40.9% | 38.5% | 27.6% | 34.7% | 26.0% | 29.0% | 21.8% |
| Male | 59.9% | 58.1% | 60.5% | 71.8% | 64.9% | 73.8% | 69.4% | 76.8% |
| Annual household income | ||||||||
| <$75,000 | 69.5% | 71.8% | 63.7% | 65.8% | 63.0% | 52.0% | 66.7% | 62.0% |
| $75,000 or more | 30.5% | 28.2% | 36.3% | 34.2% | 37.0% | 48.0% | 33.3% | 38.0% |
| Education | ||||||||
| High school or less | 45.1% | 49.0% | 40.7% | 43.9% | 39.3% | 29.1% | 39.5% | 39.7% |
| Some college | 30.2% | 29.7% | 31.1% | 26.2% | 21.9% | 18.0% | 21.9% | 22.0% |
| Bachelor’s degree or above | 24.7% | 21.3% | 28.2% | 29.9% | 38.7% | 52.9% | 38.5% | 38.3% |
AIAN=American Indian or Alaska Native. Other race and/or ethnicity includes Native Hawaiian or Pacific Islander, Middle Eastern or North African, mixed races and/or ethnicity, and other race and/or ethnicity because of the small number of participants in each of these groups.
Among US adults who currently use tobacco products in 2023, 12.0% (n=198; 95%CI=10.0%–14.0%) reported currently using nicotine pouches. The prevalence of dual using nicotine pouches was highest among those who currently used heated tobacco products (58.0%, 95%CI=47.8%–68.3%), followed by those who currently used smokeless tobacco products (41.5%, 95%CI=33.5%–49.4%), hookah (40.7%, 95%CI=32.5%–48.8%), other combustible tobacco products (34.1%, 95%CI=27.3%–41.0%), cigars (23.9%, 95%CI=19.2%–28.6%), electronic vaping products (21.3%, 95%CI=17.2%–25.5%), and cigarettes (12.4%, 95%CI=10.0%–14.7%).
Among those who dually used nicotine pouches with another tobacco product in 2023, a higher proportion of them continued with dual use in 2024 compared to completely switching to nicotine pouches, stopping use of both products, or stopping use of nicotine pouches but continuing use of another tobacco product (Table 2). Specifically, among US adults who dually used nicotine pouches with any other tobacco product in 2023, 47.1% (95%CI=38.4%–55.8%) continued dual use of nicotine pouches with other tobacco products in 2024; 42.8% (95%CI=34.2%–51.4%) stopped using nicotine pouches but currently used other tobacco products in 2024; 10.1% (95%CI=3.0%–17.2%) stopped using all tobacco products (including nicotine pouches) in 2024; and none switched to nicotine pouches only in 2024. These proportions varied somewhat by the product dually used with nicotine pouches. Notably, among those who dually used nicotine pouches and smokeless tobacco products in 2023, 47.8% (95%CI=36.4%n–59.2%) continued dual use of both products in 2024, while 30.2% (95%CI=18.8%–41.6%) stopped using both products in 2024. Additionally, 16.2% (95%CI=7.1%–25.3%) stopped using nicotine pouches but continued using smokeless tobacco products in 2024, and only 5.8% (95%CI=1.0%–10.6%) switched from smokeless tobacco products to nicotine pouches in 2024.
Table 2.
US adults who used nicotine pouches dually with another tobacco product in 2023 and their trajectories in 2024.
| Patterns between 2023 and 2024 | ||||
|---|---|---|---|---|
|
|
||||
| Switched to nicotine pouches exclusively | Dual use both products | Stopped both products | Stopped using nicotine pouches and use the other product | |
|
|
||||
| Tobacco product use in 2023 | Weighted % (95%CI) | Weighted % (95%CI) | Weighted % (95%CI) | Weighted % (95%CI) |
|
| ||||
| Any tobacco product | 0.0% (0.0%–0.0%) | 47.1% (38.4%–55.8%) | 10.1% (3.0%–17.2%) | 42.8% (34.2%–51.4%) |
| Cigarettes | 8.9% (2.6%–15.2%) | 39.8% (30.3%–49.3%) | 19.1% (9.4%–28.8%) | 32.2% (23.1%–41.3%) |
| Electronic vaping products | 9.3% (3.5%–15.0%) | 42.4% (32.1%–52.7%) | 21.1% (10.8%–31.3%) | 27.3% (17.9%–36.7%) |
| Cigars | 9.9% (3.3%–16.4%) | 37.3% (27.3%–47.2%) | 24.6% (14.1%–35.0%) | 28.3% (18.0%–38.6%) |
| Hookah | 12.4% (5.3%–19.6%) | 39.5% (27.4%–51.6%) | 28.7% (15.2%–42.3%) | 19.3% (8.3%–30.4%) |
| Heated tobacco products | 15.7% (7.2%–24.3%) | 41.8% (29.1%–54.5%) | 29.8% (16.3%–43.3%) | 12.7% (2.1%–23.3%) |
| Other combustible | 13.3% (5.5%–21.1%) | 40.4% (29.2%–51.6%) | 32.4% (20.8%–43.9%) | 13.9% (5.2%–22.7%) |
| Smokeless tobacco products | 5.8% (1.0%–10.6%) | 47.8% (36.4%–59.2%) | 30.2% (18.8%–41.6%) | 16.2% (7.1%–25.3%) |
Results from predictive marginal probability analyses showed nicotine pouch use in 2023 was not associated with higher probabilities of tobacco product use cessation in 2024 (Table 3). Specifically, current nicotine pouch use in 2023 was associated with a lower probability of quitting all tobacco product use (predictive marginal probability difference[PMPD]=−15.2%, 95%CI=−20.8%, −9.6%); quitting cigar smoking (PMPD=−19.5%, 95%CI=−32.5%, −6.5%); and quitting smokeless tobacco product use (PMPD=−18.9%, 95%CI=−33.6%, −4.3%), after adjusting for covariates (Table 3). Current nicotine pouch use in 2023 was not associated with quitting cigarettes, electronic vaping products, hookah, heated tobacco products, and other combustible tobacco products.
Table 3.
Associations between current nicotine pouch use in 2023 and stopping tobacco product use in 2024.
| Tobacco product used in 2023 | % Stopped using 2023 tobacco products in 2024 (Weighted % and 95% CI) | Predictive Marginal Probability Difference (95%CI) | |
|---|---|---|---|
|
| |||
| Used NP in 2023 | Did not use NP in 2023 | ||
|
| |||
| All other tobacco products | 10.1% (3.0%–17.2%) | 23.7% (19.8%–27.6%) | −15.2% (−20.8%, −9.6%) |
| Cigarettes | 28.0% (17.6%–38.4%) | 28.7% (24.1%–32.6%) | −3.8% (−13.1%, 5.6%) |
| Electronic vaping products | 30.3% (19.7%–41.0%) | 32.8% (28.3%–41.1%) | −7.4% (−18.2%, 3.5%) |
| Cigars | 34.4% (23.4%–45.4%) | 53.3% (46.5%–60.1%) | −19.5% (−32.5%, −6.5%) |
| Hookah | 41.2% (27.8%–54.6%) | 52.3% (41.7%–63.0%) | −10.8% (−27.3%, 5.6%) |
| Heated tobacco products | 45.5% (32.0%–59.0%) | 55.6% (39.5%–71.6%) | −11.8% (−31.6%, 8.0%) |
| Other combustible | 45.7% (33.9%–57.5%) | 46.2% (36.2%–56.2%) | −5.6% (−19.6%, 8.3%) |
| Smokeless tobacco products | 36.2% (24.5%–47.6%) | 54.3% (43.0%–65.5%) | −18.9% (−33.6%, −4.3%) |
Adjusted for age, sex, race and/or ethnicity, income, and education. Bolded estimates are statistically significant (p<0.05).
DISCUSSION
A previous study estimated around 1–2% of US adults who smoked cigarettes, 3–4% of those who use electronic vaping products, and 5% of those who use smokeless tobacco products reported also using nicotine pouches in 2023–2024.[17] While past-year quit smoking attempt (not intention to quit smoking) was associated dually using nicotine pouches with cigarettes,[16] the role of nicotine pouches in tobacco product use cessation remains unknown. We conducted the first analysis to examine the self-report changes in tobacco product use among US adults who previously dual used nicotine pouches with another tobacco product. We found that only one in ten US adults who dual used nicotine pouches with at least one other tobacco products stopped using all tobacco products, which is the desirable personal and public health outcome. Additionally, none of them switched to nicotine pouches exclusively. When examining US adults who dually using nicotine pouches with a specific product (e.g., cigarettes), the proportion of those who stopped using nicotine pouches and that specific tobacco product was around 20–30%, and the proportion of those who switched to nicotine pouches exclusively was around 10–15%. However, these figures need to be interpreted with caution, since they did not account for adults who stopped using nicotine pouches and a specific tobacco product but using a different tobacco product, or switch to nicotine pouches exclusively and using a different product. For example, someone who dually used nicotine pouches and cigarettes in 2023 and reported stopped using both products in 2024 could be using cigars in 2024 and still would be classified as “stopped using nicotine pouches and cigarettes in 2024”. Similarly, someone who dually used nicotine pouches and cigarettes in 2023 and reported currently used nicotine pouches and cigars but not cigarettes in 2024 and would be classified as “switched to nicotine pouches exclusively”. If patterns of nicotine pouch use among US adults who use tobacco products are similar to those observed in this study, nicotine pouches may have limited harm reduction potential at the population-level, despite a previous study reported that those who use nicotine pouches exclusively had lower exposure to tobacco alkaloids and lead than those who smoke cigarettes exclusively.[8] Additionally, dually using nicotine pouches with other tobacco products may represent high nicotine dependence, which may explain the association between nicotine pouch use and lower probabilities of tobacco product cessation observed in this study.
Another potential explanation for the low prevalence of switching to nicotine pouches exclusively and that nicotine pouch use in 2023 was associated with lower odds of tobacco product use cessation could be how these products have been marketed. Previous studies have examined how nicotine pouches (e.g., ZYN) were portrayed in TikTok and found that these products were presented as being for recreational purposes with very few mentioning of cessation.[21, 22] Another study examined nicotine pouch advertising and found that these advertisements focused on “freedom”, “innovation”, and “flavor”, not cessation.[23] As exposure to nicotine pouch marketing was associated with nicotine pouch experimentation in US adults[4], many of those who begin dual using nicotine pouches with another tobacco products probably did not intend to use nicotine pouches to quit using other tobacco products.
This study has several limitations. First, this is a study based on retrospective recall of commercial tobacco use to determine participants’ commercial tobacco use status in 2023, instead of a true, prospective cohort study. Therefore, the data were subjected to recall errors. However, while people who only experimented with nicotine pouches in 2023 may not be able to correctly recall their experimentation when asked in 2024, this would likely lead to underestimating the prevalence of dual use and the association between nicotine pouch use and tobacco product use cessation. Certainly, a well-powered prospective cohort study is needed to confirm our findings. Second, we did not measure detailed tobacco product consumption (i.e., days and quantities of tobacco product use) and nicotine dependence in 2023. Therefore, we were unable to adjust these variables, which could be a confounder on the association between nicotine pouch use and tobacco product use cessation. However, we conducted sensitivity analysis to additional adjusted for daily vs. non-daily tobacco product use and the results remained largely the same. Nonetheless, as in all epidemiologic studies, there could still be unmeasured confounding in the associations we estimated. Third, we could not evaluate if nicotine pouch dual use in 2023 was associated with tobacco product use reduction. It is worth noting that even substantial reductions in cigarette consumption do not necessarily translate into reduction in health risks. [24] Fourth, while it is important to examine the demographic variations in nicotine pouch and tobacco product use trajectories as well as tobacco product cessation, the small number of participants reported nicotine pouch use in 2023 hindered this investigation. Future studies need to address this potential heterogeneity in outcomes. Finally, self-reported tobacco product use cessation in 2024 may be short term and therefore the long-term cessation rate may be lower than estimated. This could further reduce the potential of nicotine pouch use in association with tobacco product use cessation to lower than the proportion we estimated.
In conclusion, we conducted the first national study of US adults who use tobacco products to examine the role of nicotine pouch use in changes in commercial tobacco use behaviors. We found that those who dually use nicotine pouches and other tobacco products were most likely to have continued dual use after a year, and few stopped using tobacco products all together or switched to exclusive nicotine pouch use. Furthermore, nicotine pouch use was associated with lower probabilities of tobacco product use cessation.
KEY MESSAGES.
What is already known on this topic:
Nicotine pouches are relatively novel nicotine products being sold globally, with US sales increased from 126 to 808 million united between 2019 and 2022. It is unclear how nicotine pouches would influence the use of other tobacco products.
What this study adds:
In a survey of US adults (≥21 years old) who recalled using tobacco products in 2023, 12.0% also recalled using nicotine pouches in 2023. Among those who used nicotine pouches with at least one more tobacco product in 2023, 47.1% continued dual use in 2024. US adults who dual-used nicotine pouches with other tobacco products in 2023 were less likely than those who did not dual-use to quit tobacco product use in 2024.
How this study might affect research, practice, or policy:
Future longitudinal studies are needed to confirm our findings that nicotine pouch use was associated with lower probabilities of quitting tobacco product use. If these findings are confirmed, nicotine pouches, as they are currently regulated in the US, may be limited in their potential to reduce tobacco-related health outcomes at the population level.
ACKNOWLEDGEMENT
FUNDING/SUPPORT:
This research was supported by the Intramural Research Program of the National Institutes of Health (NIH). The contributions of the NIH author(s) are considered Works of the United States Government. The findings and conclusions presented in this paper are those of the author(s) and do not necessarily reflect the views of the NIH or the U.S. Department of Health and Human Services.
ROLE OF FUNDER/SPONSOR:
The funding agency plays no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
DATA SHARING STATEMENT:
Please direct data sharing requests to Dr. Kelvin Choi.
ACCESS TO DATA AND DATA ANALYSIS:
Dr. Kelvin Choi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
REFERENCES:
- [1].Duren M, Atella L, Welding K, et al. Nicotine pouches: a summary of regulatory approaches across 67 countries. Tobacco Control 2024;33(e1):e32–e40. [Google Scholar]
- [2].Majmundar A, Okitondo C, Xue A, et al. Nicotine Pouch Sales Trends in the US by Volume and Nicotine Concentration Levels From 2019 to 2022. JAMA Netw Open 2022;5(11):e2242235. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Reyes-Guzman CM, Baker L, Goss-Holmes H, et al. Patterns of Emerging Tobacco Product Use Among U.S. Adults, 2019–2022. Am J Prev Med 2025;68(3):616–621. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Phan L, Zarei K, Chen-Sankey J, et al. Exposure to nicotine pouch marketing and nicotine pouch experimentation among U.S. adults who use commercial tobacco. Prev Med Rep 2024;46:102868. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [5].Tattan-Birch H, Jackson SE, Dockrell M, et al. Tobacco-free Nicotine Pouch Use in Great Britain: A Representative Population Survey 2020–2021. Nicotine Tob Res 2022;24(9):1509–1512. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Watts C, McGill B, Rose S, et al. ‘It’ll save your lungs’: early insights into nicotine pouch use and perceptions among young Australians. Health Promot Int 2024;39(6). [Google Scholar]
- [7].Zamarripa CA, Dowd AN, Elder HJ, et al. A comprehensive review on oral nicotine pouches: Available scientific evidence and future research needs. Exp Clin Psychopharmacol 2025;33(2):123–132. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Dai HD, Young B. Biomarkers of Exposure to Tobacco-Related Toxicants among Adult Nicotine Pouch Users. Nicotine Tob Res 2025. [Google Scholar]
- [9].Tran H, Tyx RE, Valentin L, et al. Total and unprotonated (freebase) nicotine content in new types of oral ‘tobacco-free’ nicotine products. Tob Control 2024. [Google Scholar]
- [10].Rungraungrayabkul D, Gaewkhiew P, Vichayanrat T, et al. What is the impact of nicotine pouches on oral health: a systematic review. BMC Oral Health 2024;24(1):889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Miluna-Meldere S, Vanka SA, Skadins I, et al. Oral mucosal changes caused by nicotine pouches: case series. Diagn Pathol 2024;19(1):127. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Miluna-Meldere S, Rostoka D, Broks R, et al. The Effects of Nicotine Pouches and E-Cigarettes on Oral Microbes: A Pilot Study. Microorganisms 2024;12(8). [Google Scholar]
- [13].Wang RJ, Bhadriraju S, Glantz SA. E-Cigarette Use and Adult Cigarette Smoking Cessation: A Meta-Analysis. Am J Public Health 2021;111(2):230–246. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Owusu D, Huang J, Weaver SR, et al. Patterns and trends of dual use of e-cigarettes and cigarettes among U.S. adults, 2015–2018. Prev Med Rep 2019;16:101009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Jackson SE, Cox S, Shahab L, et al. Trends and patterns of dual use of combustible tobacco and e-cigarettes among adults in England: A population study, 2016–2024. Addiction 2025;120(4):608–619. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Dai HD, Leventhal AM. Prevalence of Nicotine Pouch Use Among US Adults. JAMA 2024;332(9):755–757. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [17].Delnevo CD, Tomaino M, Hrywna M, et al. Patterns of Nicotine Pouch Use Among Adults in the US, 2022–2023. JAMA Netw Open 2025;8(9):e2531155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [18].Choi K, Hamilton-Moseley KR, Phan L, et al. Knowledge and Use of Menthol-Mimicking Cigarettes Among Adults in the US. JAMA Netw Open 2025;8(1):e2454608. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Rivers D Sampling for web surveys. Joint Statistical Meetings 2007. [Google Scholar]
- [20].Rivers D, Bailey D. Inference From Matched Samples in the 2008 U.S. National Elections. American Association of Public Opinion Research Joint Statistical Meeting 2009. Washington, D.C.: American Association of Public Opinion Research; 2009. [Google Scholar]
- [21].Zenone M, Harries B, Hartwell G. The Promotion of Oral Nicotine Pouches for Non-Smoking Cessation Purposes on TikTok. Nicotine Tob Res 2025. [Google Scholar]
- [22].Donaldson SI, La Capria K, DeJesus A, et al. Describing ZYN-related content on TikTok: content analysis. Nicotine Tob Res 2025. [Google Scholar]
- [23].Duan Z, Henriksen L, Vallone D, et al. Nicotine pouch marketing strategies in the USA: an analysis of Zyn, On! and Velo. Tobacco Control 2024;33(2):154–163. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [24].Chang JT, Anic GM, Rostron BL, et al. Cigarette Smoking Reduction and Health Risks: A Systematic Review and Meta-Analysis. Nicotine Tob Res 2020. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Please direct data sharing requests to Dr. Kelvin Choi.
Dr. Kelvin Choi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.