Dear Editor,
Oral nicotine pouches (ONPs) represent one of the fastest-growing segments of the nicotine market1. These products are discreet, odorless and do not require spitting, characteristics that facilitate undetected use in school. Although use remains lower than e-cigarettes, the patterns of use and sales trends suggest this may represent the early stages of a significant increase in youth nicotine exposure rather than a transient phenomenon2.
According to the 2024 US National Youth Tobacco Survey (NYTS), 1.8% of middle and high school students (approximately 480000 youth), reported current ONP use3-5. Among 10th- and 12th-grade students, ever use increased from 3.0% in 2023 to 5.4% in 2024, an 80% relative increase3.
Several characteristics of ONPs warrant concern from a public health standpoint. Nicotine exposure during adolescence adversely affects neurodevelopment, with documented effects on attention, learning, impulse control, and mood regulation6. Some ONPs contain high levels of nicotine, and product design features increase the proportion of free nicotine and enhance the rate of absorption7,8. Flavors and nicotine formulations may increase nicotine delivery, dependence risk, and abuse potential7-9. Youth-targeted marketing, extensive flavor proliferation, and amplification through social media and influencer-driven content collectively increase the appeal and normalization of ONPs among youth10-12.
Emerging real-world classroom-level data from Kentucky, a state with historically higher tobacco use, highlight how quickly ONPs have entered the youth environment. In 2024–2025, among a convenience sample of sixth-12th graders who received the #iCANendthetrend (ICETT) near-peer tobacco prevention program (N=3167)13,14, 6% of high school and nearly 3% of middle school students reported ONP use the prior year; no students reported ONP use in the prior program year15. Additionally, youth in more rural communities reported higher ever use of ONPs15, suggesting emerging social-environmental disparities from distinct exposure pathways, access points, and social norms surrounding discreet nicotine products. In response, the ICETT program was adapted in 2024 to integrate explicit ONP-focused education addressing nicotine-related harms, misconceptions associated with ‘tobacco-free’ labeling, youth-targeted marketing, and addiction potential.
Similarly, in a randomized controlled trial of UP2UTeacher, a classroom-based brief tobacco and nicotine intervention, among 548 ninth-grade students from 10 Virginia high schools16, 5.4% reported ONP use. Following the intervention, perceptions of ONP harm and addictiveness increased significantly, suggesting students are receptive to this information16.
These data carry several implications for public health research and practice.
First, prevention curricula should explicitly address ONPs, including nicotine-related harms, marketing tactics, and the misconceptions surrounding ‘tobacco-free’ labeling. Youth perspectives should inform educational materials and peer-to-peer messaging.
Second, educators, parents, and healthcare providers need greater awareness of ONPs through school-based training, family communication resources, and routine clinical screening.
Third, longitudinal studies examining youth susceptibility, behavioral trajectories, health effects, and risk for product escalation are essential to inform regulatory action and evidence-based prevention.
Surveillance data, program observations, and accelerating sales collectively suggest a narrowing window for intervention. Coordinated efforts to modernize prevention programming, expand stakeholder engagement, and invest in targeted research will be critical to mitigating the public health consequences of this emerging product.
Funding Statement
This work is supported by a grant to ML from the Virginia Foundation for Healthy Youth (8521389) and the National Cancer Institute (R01CA267963). In addition, this work was supported by a grant to MI from the Kentucky Department for Public Health.
Footnotes
Conflicts of Interest: The authors have completed and submitted an ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. M. Little reports that since the initial planning of the work she was funded by the Virginia Foundation for Healthy Youth and the Kentucky National Cancer Institute (8521389) and (R01CA267963). M. Ickes reports that since the initial planning of the work she was funded by the Kentucky Department for Public Health.
Ethical Approval and Informed Consent: Ethical approval and informed consent were not required for this study.
Data Availability: The data supporting this research are available from the authors on reasonable request.
Authors’ Contributions: Both authors: contributed equally to this work, conceptualized the study, designed the methodology, interpreted the findings, drafted the manuscript, critically revised the manuscript, and interpreted the results. Both authors read and approved the final version of the manuscript.
Provenance and Peer Review: Commissioned; internally peer reviewed.
Disclaimer: The views and opinions expressed in this article are those of the authors.
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