Correlates of Oral Nicotine Pouch Use, Use Frequency, and Flavor Use Among US Adults

Abstract

Background

As oral nicotine pouches (ONPs) gain popularity in the US, little is known from nationally representative data about who uses them and how they are being used.

Objectives

To examine tobacco use and sociodemographic correlates of ONP use, use frequency, and flavor use among US adults.

Methods

Data were drawn from the 2022–2023 Tobacco Use Supplement to the Current Population Survey (N=157,485). Weighted logistic regression models were used to identify predictors of (1) current ONP use, (2) daily vs. non-daily ONP use, and (3) flavored vs. unflavored ONP use.

Results

The odds of current ONP use were higher among younger adults, males, non-Hispanic Whites, individuals with higher income, and those who had ever used cigarettes, e-cigarettes, or smokeless tobacco (SLT). People who currently use cigarettes, e-cigarettes, or SLT had lower odds of daily (vs. non-daily) ONP use, whereas people with a history of cigarette use who do not currently smoke had higher odds. Males, younger adults, and people with a history of SLT use who do not currently use SLT were more likely to use flavored ONPs.

Conclusions

ONP use was common among individuals with current and prior tobacco use, which may be consistent with alternative nicotine use. However, a small proportion of ONP users reported no prior use of other tobacco products, highlighting the need for continued research on nicotine uptake through ONPs among tobacco-naïve populations, particularly among young adults. In addition, the prevalence of co-use with other tobacco products may limit potential public health benefits.

Introduction

The tobacco and nicotine marketplace has been rapidly evolving in response to product innovation, regulatory changes, and shifting consumer preferences. Since 2017, a novel nicotine product, oral nicotine pouches (ONPs), has emerged in the United States (US) market. Characterized by a wide range of flavors and nicotine concentrations, and by their non-combustible mode of nicotine delivery, ONPs have quickly gained popularity, particularly among adolescents and young adults (AYAs). National survey data indicate a steady increase in use, with past 30-day use prevalence among high school students rising from 1.1% in 2021 to 1.4% in 2022 and reaching 2.4% in 2024.^1–3 In comparison, ONP use among adults remains relatively lower, with 3.3% reporting ever use and 0.8% reporting past 30-day use in 2023.⁴

Although ONPs are still less popular than cigarettes, e-cigarettes, and smokeless tobacco (SLT) among the general population, their sales have increased exponentially in recent years. A recent study reported that monthly ONP sales more than tripled between 2021 and 2024, from 327 million to over 1.05 billion units (1 unit = 1 pouch), making ONPs one of the fastest-growing nicotine products in the US market.⁵ ONPs are unique in that they do not contain tobacco leaf and do not involve combustion, making them a substantially “lower-risk product” relative to combustible tobacco.^6–8 However, ONPs still expose users to nicotine and increase the potential risk of addiction and escalation of tobacco use.^9–11 From a public health standpoint, harm can be reduced if adults use ONPs to quit smoking or SLT use. In contrast, harm may increase if AYAs initiate nicotine and tobacco use through ONPs.⁹ Therefore, the net public health impact depends on who uses them, how they are used, and under what circumstances.

Despite their rapid growth, patterns of ONP use remain poorly understood. Prior studies suggest that those who use ONPs share demographic characteristics with those who use SLT, with higher use observed among males, non-Hispanic Whites, and individuals with lower income.^{4, 12, 13} Younger adults also appear more likely than older adults to use ONPs.^{4, 14} ONP use is further associated with prior use of other tobacco products (i.e., cigarettes, e-cigarettes, SLT, etc.).^{4, 12–15} However, most of this evidence is based on AYA samples (aged 15–24),^12–14 many of which are not nationally representative.^{12, 14} Consequently, population-level estimates remain limited. To the best of our knowledge, several studies to date have used a nationally representative adult sample to examine correlates of ONP use; however, they did not assess factors associated with use frequency or flavor use.^{4, 16–18} Understanding who uses ONPs more frequently is important because frequent use may reflect a transition from other tobacco products and potential use as a harm-reduction or cessation tool. Currently, no national evidence indicates whether adults, particularly those with a history of tobacco use, are using ONPs for harm reduction. Examining patterns of ONP use across tobacco use groups may provide indirect insights into how these products are being used in relation to other tobacco products, which may be relevant to discussions of their potential role in harm reduction. In addition, the roles of flavor use and residential location (urban vs. rural) in shaping ONP use patterns remain unclear. Identifying these associations is critical for informing regulatory decisions, including potential flavor restrictions and evaluations under the Food and Drug Administration’s Premarket Tobacco Product Application (PMTA) process, as such evidence can guide product reviews and public health assessments.

Obtaining robust evidence on who uses ONPs, how often, and under what conditions is crucial for establishing a foundational understanding of this emerging nicotine product. This study aims to examine the full range of factors associated with ONP use, frequency of use, and flavor use, thereby providing evidence to guide future prevention efforts and regulatory actions.

Data and Methods

Data Source

Data were obtained from the 2022–2023 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), a nationally representative survey of the US civilian, noninstitutionalized population aged 18 or older.¹⁹ Since 1992, the TUS-CPS has served as a key source of national, state, and sub-state data on tobacco use behavior, attitudes, and related factors in the US. The survey is sponsored by the National Cancer Institute (NCI) and administered as part of the Current Population Survey (CPS), a monthly survey conducted by the US Census Bureau in collaboration with the Bureau of Labor Statistics. The most recent TUS-CPS, fielded between September 2022 and May 2023, introduced new items assessing ONP use. This study used data from the September 2022 (n=52,671), January 2023 (n=52,084), and May 2023 (n=52,730) survey waves, yielding a total sample size of 157,485 for analysis.

Respondents were either self-interviewed (72.5%) or represented by a proxy household member (27.5%) when the target respondent was unavailable. Proxy respondents, who reside in the same household, may be able to report observable behaviors, such as whether an individual currently uses ONPs and whether use is daily or non-daily. However, proxy respondents did not provide answers to ONP flavor use, resulting in missing data for this variable.

Study Measures

Current use of cigarettes, e-cigarettes, SLT, and ONPs was assessed using the following questions: “Do you now smoke cigarettes every day, some days, or not at all?” “Do you now use an e-cigarette every day, some days, or not at all?” “Do you now use SLT such as moist snuff, dip, spit, chew tobacco, or snus every day, some days, or not at all?” “Do you now use nicotine pouches every day, some days, or not at all?” For each product, responses were categorized into a binary indicator of current use: 1 = every day or some days; 0 = not at all. The variable “ONP use frequency” was further categorized as daily use (coded as 1) or non-daily use (coded as 0) among current ONP users. Furthermore, the survey asked the respondents whether they had ever smoked at least 100 cigarettes in their entire life, and used e-cigarettes or SLT even one time. Based on these responses, we constructed three variables, “cigarette use history”, “e-cigarette use history”, and “SLT use history”, coded as 0 if they had never used such a product, 1 if they currently use such a product, and 2 if they previously used such a product.

Flavor use was assessed by asking respondents whether, during the past 30 days, they had used menthol, mint, clove, spice, herb, fruit-flavored, or unflavored ONPs. Based on these responses, we created a variable “Flavor use”, coded as 1 = flavored ONPs and 0 = unflavored ONPs. This categorization was developed to capture differences in how flavors are presented and perceived by consumers. Given that the survey instrument assessed specific named flavors but did not capture brand-level marketing descriptors, grouping responses into “flavored” versus “unflavored” categories allowed for a consistent and interpretable classification across respondents. Because a substantial proportion of current ONP users (45%) did not report their flavor type (44% are self-responses and 56% are proxy responses), we included a separate “Flavor missing” indicator variable (1 = missing flavor information; 0 = reported flavor) to retain all observations in models examining ONP use frequency.

Individual-level sociodemographic variables included residential location (urban vs. rural), age, sex (female vs. male), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, non-Hispanic others [i.e., American Indian, Alaska Native, native Hawaiian, and Other Pacific Islander], and non-Hispanic multiracial), family income (low: <$40,000; medium: $40,000–$100,000; high: >$100,000), and educational attainment (high school diploma or less, associate degree, and bachelor’s degree or higher). Urban/rural status was assigned by the US Census Bureau based on respondents’ county of residence, classifying areas as metropolitan (urban) or non-metropolitan (rural).

Statistical Analysis

We began our analysis by presenting summary statistics for the analytic sample used in Model 1 predicting current ONP use, followed by the characteristics of current ONP users. Given that ONP use is particularly popular among young adults, we also report detailed characteristics for this subgroup.

Three logistic regression models were estimated separately. Model 1 used the full analytical sample (n = 155,857) to assess the association between current ONP use (yes/no) and other tobacco product use history (cigarettes, e-cigarettes, SLT), as well as individual-level sociodemographic variables. To maximize sample size, both self-responses and proxy responses were included, and an indicator for proxy response was incorporated into Model 1. Model 2 was restricted to people who currently use ONPs (n=715) and examined factors associated with ONP use frequency (daily vs. non-daily). This model included all explanatory variables from Model 1, along with two flavor-related variables: (1) an indicator of flavored (vs. unflavored) ONP use among respondents with non-missing flavor data, (2) an indicator for missing flavor information (yes vs. no) to account for nonresponse. Because flavor information was missing for proxy respondents (n=179, 56%) and a subset of self-respondents (n=142, 44%), the missing-flavor indicator was included to retain these respondents in the analysis. As in model 1, a separate proxy-response indicator was included to account for potential differences between self- and proxy-reported respondents. The race/ethnicity variable was omitted from the regression model because some racial/ethnic categories contained too few observations to support reliable estimation. Model 3 further restricted the sample to those who currently use ONPs with non-missing flavor information (n=394) and examined factors associated with flavor use. Explanatory variables in Model 3 included tobacco use history and sociodemographic characteristics.

In Model 1, the variable for current ONP use had 11 missing values, while residential location had 1,617 missing values; all other variables were complete. To assess whether the missing data were missing completely at random (MCAR), we conducted Little’s MCAR test.²⁰ The test yielded a p-value of 0.36, indicating no evidence against the MCAR assumption. Thus, the missing values in current ONP use and residential location can be reasonably considered missing completely at random, which reduced the analytic sample from 157,485 to 155,857. All analyses incorporated replicate weights to account for the complex survey design to produce correct standard errors and confidence intervals. Statistical analyses were conducted using Stata 19 (StataCorp LLC, College Station, TX).

Sensitivity analysis

We conducted two sensitivity analyses for Models 1 and 2 by restricting the sample to self-responses only to evaluate the potential impact of misclassification associated with proxy responses on the regression results.

Results

Sample Characteristics

Table 1 presents the weighted summary characteristics of the analytic sample used in Model 1 predicting current ONP use. For comparison, characteristics of young adults aged under 24 are also shown. Approximately 0.4% of US adults reported current ONP use. The prevalence of current cigarette smoking was 9.0%, higher than that of e-cigarette use (2.7%) and SLT use (1.1%). The mean age of respondents was 48 years (range: 18–85), and the majority identified as non-Hispanic White (61.5%). Overall, 87.3% of respondents resided in urban areas, compared with 12.7% in rural areas.

Table 1:

Weighted descriptive characteristics of the analytic sample for Model 1

Variables	All Sample (n=155,857)		Age 18–24 (n=11,201)
	Mean (SD) / %	95% CI	Mean (SD) / %	95% CI
ONP current use	0.40%	[0.36%, 0.43%]	0.48%	[3.7%, 6.3%]
Cigarette use histories
Current smokers	9.01%	[8.84%, 9.18%]	3.94%	[3.55%, 4.36%]
Former smokers	15.81%	[15.61%, 16.01%]	2.65%	[2.34%, 2.99%]
Never smokers (ref group)	75.18%	[74.93%, 75.43%]	93.41%	[92.88%, 93.91%]
E-cigarette use histories
Current e-cigarette users	2.69%	[2.59%, 2.79%]	6.30%	[5.81%, 6.83%]
Former e-cigarette users	5.29%	[5.16%, 5.43%]	6.55%	[6.04%, 7.09%]
Never e-cigarette users (ref group)	92.02%	[91.85%, 92.18%]	87.15%	[86.42%, 87.85%]
SLT use histories
Current SLT users	1.12%	[1.06%, 1.18%]	0.58%	[0.45%, 0.74%]
Former SLT users	3.99%	[3.88%, 4.10%]	1.89%	[1.63%, 2.20%]
Never SLT users (ref group)	94.90%	[94.77%, 95.02%]	97.53%	[97.19%, 97.83%]
Sex
Female (ref group)	51.24%	[50.94%, 51.54%]	49.82%	[48.71%, 50.92%]
Male	48.76%	[48.46%, 49.06%]	50.18%	[49.08%, 51.29%]
Age	48.027 (18.349)	[47.914, 48.139]	21.041 (2.013)	[20.996, 21.085]
Race/ethnicity
non-Hispanic White (ref group)	61.46%	[61.16%, 61.77%]	51.64%	[50.53%, 52.74%]
non-Hispanic Black	12.12%	[11.90%, 12.34%]	13.60%	[12.78%, 14.46%]
Hispanic	17.40%	[17.15%, 17.65%]	24.08%	[23.15%, 25.05%]
non-Hispanic Asian	6.43%	[6.28%, 6.59%]	6.07%	[5.55%, 6.62%]
non-Hispanic others	1.00%	[0.94%, 1.69%]	1.17%	[0.96%, 1.43%]
non-Hispanic Multi-race	1.60%	[1.51%, 1.69%]	3.45%	[3.03%, 3.92%]
Geographic location
Urban (ref group)	87.34%	[87.16%, 87.51%]	87.93%	[87.25%, 88.57%]
Rural	12.66%	[12.49%, 12.84%]	12.07%	[11.43%, 12.75%]
Family income
High income	36.54%	[36.24%, 36.83%]	34.38%	[33.31%, 35.46%]
Medium income (ref group)	37.99%	[37.69%, 38.28%]	37.18%	[36.13%, 38.25%]
Low income	25.48%	[25.22%, 25.74%]	28.44%	[27.49%, 29.42%]
Educational attainment
Bachelor’s degree or higher	35.75%	[35.47%, 36.03%]	13.30%	[12.61%, 14.03%]
Associate degree (ref group)	26.54%	[26.27%, 26.81%]	37.16%	[36.09%, 38.23%]
High school diploma or less	37.71%	[37.41%, 38.01%]	49.54%	[48.44%, 50.65%]

Among all people who currently use ONPs (n=715), 42.2% used ONPs daily, and 57.9% used them non-daily (Table 2). Most people who currently use ONPs (77.7%) reported using flavored products, while 22.3% used unflavored products. Co-use with other tobacco products was common: 24.8%, 21.0%, and 28.6% of those who currently use ONPs were also concurrently using cigarettes, e-cigarettes, and SLT, respectively, and 91.8% had ever used at least one of these three tobacco products. People who currently use ONPs were, on average, younger (mean age = 39 years) than the overall sample (mean age = 48 years). The vast majority were male (89.5%) and non-Hispanic White (86.6%). Compared with the overall population, a higher proportion of people who currently use ONPs resided in rural areas (19.9% vs. 12.7%) and reported higher income levels (43.3% vs. 36.5%).

Table 2:

Weighted characteristics of adults who currently use (daily or non-daily) oral nicotine pouches (Model 2).

Variables	All Sample (n=715)		Age 18–24 (n=78)
	Mean (SD) / %	95% CI	Mean (SD) / %	95% CI
ONP use frequencies
Daily use	42.15%	[37.84%, 46.59%]	30.19%	[19.41%, 43.72%]
Non-daily use	57.85%	[53.41%, 62.16%]	69.81%	[56.28%, 80.59%]
Flavor use
Flavored ONP use	77.73%	[71.84%, 82.69%]	80.32%	[59.69%, 91.84%]
Unflavored ONP use	22.27%	[17.31%, 28.16%]	19.68%	[8.16%, 40.31%]
Use histories of any of the three tobacco products
Ever users	91.77%	[88.96%, 93.92%]	89.88%	[77.16%, 95.89%]
Never users	8.23%	[6.08%, 11.04%]	10.12%	[4.11%, 22.84%]
Cigarette use histories
Current smokers	24.75%	[21.04%, 28.87%]	19.86%	[11.38%, 32.36%]
Former smokers	35.40%	[31.32%, 39.70%]	14.93%	[7.95%, 26.26%]
Never smokers (ref group)	39.85%	[35.48%, 44.39%]	65.21%	[51.65%, 76.69%]
E-cigarette use histories
Current e-cigarette users	21.04%	[17.34%, 25.28%]	51.33%	[37.57%, 64.89%]
Former e-cigarette users	30.28%	[26.39%, 34.48%]	26.26%	[16.28%, 39.47%]
Never e-cigarette users (ref group)	48.68%	[44.21%, 53.17%]	22.41%	[13.03%, 35.77%]
SLT use histories
Current SLT users	28.56%	[24.69%, 32.77%]	20.65%	[12.41%, 32.34%]
Former SLT users	37.06%	[32.83%, 41.50%]	40.53%	[27.38%, 55.19%]
Never SLT users (ref group)	34.38%	[30.22%, 38.79%]	38.82%	[26.38%, 52.93%]
Sex
Female (ref group)	10.47%	[8.02%, 13.55%]	8.53%	[3.68%, 18.55%]
Male	89.53%	[86.44%, 91.98%]	91.47%	[81.45%, 96.32%]
Age	39.233 (14.140)	[37.947, 40.519]	22.053 (1.879)	[21.538, 22.568]
Race/ethnicity
non-Hispanic White (ref group)	86.61%	[82.83%, 89.66%]	91.96%	[78.40%, 97.30%]
non-Hispanic Black	4.65%	[2.74%, 7.81%]	3.66%	[0.50%, 22.31%]
Hispanic	5.36%	[3.61%, 7.88%]	2.72%	[0.65%, 10.65%]
non-Hispanic Asian	0.58%	[0.18%, 1.78%]	-	-
non-Hispanic others	0.85%	[0.35%, 2.02%]	-	-
non-Hispanic Multi-race	1.96%	[1.00%, 3.80%]	1.66%	[0.22%, 11.34%]
Geographic location
Urban (ref group)	80.14%	[76.48%, 83.36%]	75.80%	[61.65%, 85.91%]
Rural	19.86%	[16.64%, 23.52%]	24.20%	[14.09%, 38.34%]
Family income
High income	43.31%	[38.87%, 47.86%]	43.62%	[30.11%, 58.14%]
Medium income (ref group)	36.62%	[32.48%, 40.96%]	25.65%	[16.01%, 38.43%]
Low income	20.08%	[16.71%, 23.92%]	30.74%	[20.02%, 44.03%]
Educational attainment
Bachelor’s degree or higher	30.86%	[26.91%, 35.11%]	21.13%	[12.30%, 33.85%]
Associate degree (ref group)	32.47%	[28.41%, 36.82%]	40.17%	[27.51%, 54.28%]
High school diploma or less	36.66%	[32.41%, 41.14%]	38.70%	[25.91%, 53.27%]
Flavor missing
Yes	45.09%	[40.66%, 49.59%]	38.39%	[25.96%, 52.55%]
No	54.91%	[50.41%, 59.34%]	61.61%	[47.45%, 74.04%]

When we further restricted the sample to young adults who currently use ONPs, we found that 69.8% used ONPs non-daily, suggesting that most young adults may engage in experimental use or co-use with other tobacco products. Among young adults who currently use ONPs, 65.2% had never smoked cigarettes, compared with 39.9% of ONP users overall. However, only 22.4% had never used e-cigarettes, compared with 48.7% of ONP users overall. In addition, 51.3% of young adults who currently use ONPs concurrently used e-cigarettes, more than double the proportion observed among all ONP users (21.0%). Moreover, among young adults who currently use ONPs, 20.7% concurrently used SLT and 40.5% had previously used SLT. This pattern suggests that many young adults who currently use ONPs may have current or prior experience with non-cigarette tobacco products, particularly e-cigarettes, underscoring the need to examine ONPs within the broader context of multiple-product nicotine use. The descriptive statistics of the sample for Model 3 can be found in Supplementary Table 1.

Use Prevalence

Figure 1 displays adjusted odds ratios from Model 1 predicting current ONP use. Compared with those who never used cigarettes, e-cigarettes, and SLT, those who currently used cigarettes (OR = 1.86, 95% CI: 1.35–2.56), e-cigarettes (OR = 3.60, 95% CI: 2.58–5.03), and SLT (OR = 29.79, 95% CI: 22.06–40.23) had higher odds of current ONP use. Similarly, those who previously used cigarettes, e-cigarettes, and SLT also had higher odds of current ONP use (cigarettes: OR = 1.62, 95% CI: 1.23–2.13; e-cigarettes: OR = 2.67, 95% CI: 2.03–3.50; SLT: OR = 7.86, 95% CI: 5.82–10.61). The odds of current ONP use were significantly higher among males (OR=3.49, 95% CI: 2.56–4.77) and younger respondents (OR=0.97, 95% CI: 0.97–0.98). Compared with non-Hispanic White adults, Hispanic (OR=0.40, 95% CI: 0.26–0.61) and Asian adults (OR=0.14, 95% CI: 0.04–0.45) had significantly lower odds of current ONP use. Compared with individuals in the medium-income group, those with higher incomes had higher odds of ONP use (OR=1.29, 95% CI: 1.03–1.61). In contrast, respondents with a high school diploma or less had lower odds compared to those with an associate degree (OR=0.77, 95% CI: 0.61–0.97).

Figure 1:

Adjusted Odds Ratios for Correlates of Current Oral Nicotine Pouch Use (Model 1)

Note: *** p<0.001, ** p<0.01, * p<0.05

Frequency of Use

Figure 2 presents the results from Model 2 predicting ONP use frequency (daily vs. non-daily). Compared with those who never used cigarettes, e-cigarettes, and SLT, those who currently use cigarettes (OR=0.25, 95% CI: 0.13–0.48), e-cigarettes (OR=0.26, 95% CI: 0.13–0.51), and SLT (OR=0.44, 95% CI: 0.26–0.74) had lower odds of daily ONP use. In contrast, people who previously smoked cigarettes (OR=2.85, 95% CI: 1.75–4.62) and individuals with a high school diploma or less (OR=1.89, 95% CI: 1.15–3.12) had higher odds of daily ONP use. Flavored ONP use and other sociodemographic characteristics were not significantly associated with the frequency of use. Although rural residence was associated with higher odds of daily ONP use, the association did not reach statistical significance (p=0.08).

Figure 2:

Adjusted Odds Ratios for Correlates of Daily vs. Non-daily Oral Nicotine Pouch Use (Model 2)

Note: *** p<0.001, ** p<0.01, * p<0.05

Flavor Use

Figure 3 shows odds ratios from Model 3 predicting ONP flavor use. Compared with individuals who never used SLT, those who previously used SLT had higher odds of using flavored ONPs (OR=3.07, 95% CI: 1.21–7.82). Similarly, males had higher odds (OR=3.27, 95% CI: 1.12–9.55) of using flavored ONPs compared with females. In contrast, older adults (OR=0.97, 95% CI: 0.95–1.00) and those with a high school diploma or less (OR=0.41, 95% CI: 0.17–1.00) were less likely to use flavored ONPs. Other sociodemographic characteristics were not significantly associated with flavor use.

Figure 3:

Adjusted Odds Ratios for Correlates of Flavored vs. Unflavored ONP Use (Model 3)

Note: *** p<0.001, ** p<0.01, * p<0.05

Sensitivity analyses for Models 1 and 2 yielded results consistent with the main findings, with similar coefficient estimates and significance levels after restricting the sample to self-responses only. Results are shown in Supplementary Table 2.

Discussion and Conclusion

This study examined a comprehensive set of factors associated with current ONP use, use frequency, and flavor use. Current ONP use was significantly associated with current and ever non-current use of cigarettes, e-cigarettes, and SLT, consistent with prior research.^12–14 Descriptive results showed that nearly all adults who currently use ONPs (92%) had ever used other tobacco products. These pattern suggests that ONPs are primarily used by individuals with prior or concurrent tobacco use, which may be consistent with a harm-reduction role if ONPs substitute for more harmful tobacco products. However, a small proportion of ONP users reported no prior use of cigarettes, e-cigarettes, or SLT, highlighting the need for continued surveillance of ONP uptake among tobacco-naïve populations. The concurrent use of ONPs with other tobacco products was also prevalent, indicating that dual or poly-use may offset potential health benefits. This concern is particularly salient among young adults, more than half of whom reported using ONPs concurrently with e-cigarettes. Future prevention efforts should prioritize this age group and develop strategies aimed at reducing ONP initiation and co-use with other nicotine products.

The odds of daily ONP use were significantly lower among those who currently use cigarettes, e-cigarettes, and SLT but higher among those who previously smoked cigarettes. This pattern suggests that individuals who co-use ONPs with other tobacco products are more likely to use ONPs non-daily, whereas those who previously smoked are more likely to use ONPs daily. These associations may reflect differences in patterns of ONP use across tobacco use groups. The higher likelihood of daily ONP use among those who previously smoked may be consistent with alternative nicotine use; however, substitution between products cannot be established using cross-sectional data. Future research using longitudinal designs is needed to examine potential substitution behaviors between smoking and ONP use.

We incorporated flavor use into our analysis of ONP use frequency, which was not previously reported in the literature. We did not find a significant association between flavor use and use frequency. However, people who previously used SLT were more likely to use flavored ONPs, which may reflect continuity in product preferences, as flavored SLT products have historically been widely marketed and used.^{21, 22} This finding suggests that prior experience with flavored smokeless tobacco products may influence flavor selection in newer nicotine products such as ONPs. We also observed that males were more likely to use flavored ONPs, whereas older adults and those with a high school diploma or less were less likely to do so. These patterns are broadly consistent with prior research indicating that flavored tobacco products tend to be more appealing to younger individuals, whereas older adults may prefer less prominently flavored or unflavored products.²³ This suggests that use of flavored ONPs varies across sociodemographic groups, which may have implications for understanding how flavor-related regulations could affect different segments of the population. However, given the limited sample size, these findings should be interpreted with caution.

We found that males, younger adults, and non-Hispanic Whites had higher odds of current ONP use, in line with prior literature.^{4, 12, 13, 24} However, individuals with higher income also had increased odds of ONP use compared with those in the medium-income group, contrary to previous studies that reported greater ONP use among lower-income individuals.^{12, 13} This discrepancy may reflect evolving market dynamics; our research similarly shows that ONP sales per capita are higher in high-income counties than in medium- or low-income counties.²⁵ Additionally, individuals with a high school diploma or less had lower odds of current ONP use and flavored ONP use than those with an associate degree, but they were more likely to use ONPs daily, suggesting differences in patterns of ONP use by educational attainment.

This study has several limitations. First, because the TUS-CPS is cross-sectional, our findings cannot establish causal relationships. Longitudinal data are needed to clarify whether there is a causal link between other tobacco use and ONP use. Second, analyses of ONP use frequency and flavor use were based on relatively small subsamples of current users. This limitation is particularly relevant for the flavor use model. This may reduce statistical power and limit generalizability. Results from these analyses should be considered exploratory and interpreted with caution. Finally, we did not adjust for tobacco control policies (e.g., smoke-free air laws, age restrictions, or flavor bans). These policies may influence the use of combustible or inhaled nicotine products, and some product-specific regulations, such as flavor bans, may also directly affect ONP use. Although ONPs are discreet, easy to conceal, and exempt from many place-based restrictions,^{26, 27} policy environments may shape both ONP use and the broader tobacco marketplace. Future research linking individual-level data with policy databases should further evaluate these potential contextual effects.

In conclusion, this study provides new evidence on the patterns and correlations of ONP use among US adults using nationally representative data. Our findings highlight distinct user profiles and behavioral patterns that carry both harm-reduction potential and public health risks. While ONP use was most common among individuals with current or prior tobacco use, a small proportion of ONP users reported no prior use of cigarettes, e-cigarettes, or SLT. These findings highlight the need for continued research on the role of ONPs in nicotine uptake among tobacco-naïve populations, particularly among young adults. Moreover, the high prevalence of ONP co-use with other tobacco products may diminish the potential health benefits associated with transitioning from traditional tobacco use to exclusive ONP use. Continued monitoring of ONP use, particularly among younger populations, is critical as the marketplace and regulatory landscape evolve. Future research should evaluate longitudinal trajectories of ONP use, assess the impact of flavor regulations, and explore how ONPs fit within broader patterns of nicotine and tobacco product substitution and co-use.

What is already known on this topic:

• Oral nicotine pouches (ONPs) are a rapidly growing segment of the US nicotine market, promoted as tobacco-free and lower-risk alternatives to cigarettes and smokeless tobacco (SLT).

• Previous studies have described ONP awareness and use primarily among adolescents and young adults, but nationally representative evidence among US adults remains limited.

• Existing research has not comprehensively examined how ONP use frequency and flavor use vary by tobacco use history and sociodemographic characteristics.

What this study adds:

• Using 2022–2023 data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS), this study identifies behavioral and sociodemographic correlates of ONP use, use frequency, and flavor use.

• Nearly all people who use ONPs had a history of other tobacco use, and co-use with other products was common, particularly concurrent use with e-cigarettes among young adults.

• People who currently or formerly used cigarettes, e-cigarettes, or SLT had significantly higher odds of ONP use.

• Compared with non-daily use, daily ONP use was significantly less likely among those who currently smoke cigarettes but more likely among those who previously smoked cigarettes.

How this study might affect research, practice, or policy:

• Findings highlight the need for continued surveillance of ONP uptake, particularly among young adults and people who never smoke.

• Evidence of frequent ONP use among people who previously smoked supports evaluating ONPs’ role in harm reduction, while high rates of co-use suggest potential offsets to these benefits.

• Policymakers should consider the implications of flavor availability and marketing strategies that may appeal to young or nicotine-naïve populations.

• Results can inform future regulatory efforts and public health messaging aimed at preventing ONP initiation while supporting cessation among adults who smoke.