“Tobacco-free” Nicotine Pouches: Risk Perceptions, Awareness, Susceptibility, and Use Among Young Adults in the United States

Abstract

Background

Nicotine pouches containing synthetic nicotine or tobacco-derived nicotine (TDN) are available in the United States. Synthetic nicotine pouches are often marketed as “tobacco-free nicotine” (TFN), which may alter risk perceptions and product appeal. This study examined young adults’ perceptions of TFN versus TDN pouches and the associations between product perceptions and TFN pouch awareness, susceptibility, and use, respectively.

Aims and Methods

In total 630 young adults (18–25 years) completed an online Qualtrics panels survey in 2021. Participants were informed that TFN pouches contain synthetic nicotine as opposed to TDN. Participants reported on comparative risk perceptions for TFN versus TDN pouches and on TFN pouch awareness, susceptibility, and use. Unadjusted between-group comparisons and adjusted binary logistic regressions were run to examine relationships between product perceptions and TFN pouch awareness, susceptibility, and use.

Results

Participants were aware of (37.3%), susceptible to (29.2%), or had used TFN pouches (3.8%). In unadjusted comparisons, TFN pouch awareness, susceptibility, and use were associated with disproportionately perceiving TFN pouches as less harmful or otherwise better than TDN pouches. In adjusted models, relationships between favorable perceptions and both TFN pouch awareness and susceptibility remained significant.

Conclusions

The descriptor “tobacco-free” may impact risk perceptions and the appeal of nicotine pouches among young adults. While no direct relationship was observed between TFN perceptions and TFN pouch use in the adjusted model, perceptions remained related to product awareness and susceptibility, which may be linked to future use. Continued surveillance is needed to fully determine how the term “tobacco-free” on product packaging and advertising impacts longitudinal public health outcomes.

Implications

Nicotine pouches originally contained TDN. Today, numerous brands of synthetic nicotine pouches, which are often marketed as “tobacco-free,” are available on the market. We informed participants that “tobacco-free nicotine” pouches contain synthetic nicotine and examined comparative risk perceptions (i.e. tobacco-free vs. TDN pouches) and TFN pouch awareness, susceptibility, and use. Perceiving tobacco-free nicotine pouches as less harmful than tobacco-derived pouches was associated with product awareness, susceptibility, and use in unadjusted models and with awareness and susceptibility in adjusted models. Restricting the term “tobacco-free” may become necessary if the term inaccurately reduces product risk perceptions or increases product appeal.

Introduction

Oral nicotine pouches were introduced to the US mass market in 2016. Nicotine pouches are small, prefilled, fiber pouches that contain nicotine.¹ Similar to snus and traditional smokeless tobacco, nicotine pouches are put in-between the lip and the gum, and nicotine is absorbed orally. Using nicotine pouches does not require any spitting.¹ U.S. sales data indicated a large increase in nicotine pouch unit sales from 2016 (163 178) to 2020 (45 965 455),² suggesting that these products are rapidly gaining popularity.

The increasing availability of nicotine pouches in the US market may lead to public health benefits or harm. On one hand, early research shows that most adults who use nicotine pouches currently use or previously used smokeless tobacco.³ Nicotine pouches contain a comparable amount of nicotine to smokeless tobacco⁴ but with fewer harmful chemicals (even than snus—a modified-risk tobacco product).⁵ With adequate nicotine delivery to prevent nicotine withdrawal⁴ and a toxicant profile similar to that of nicotine replacement therapies,⁵ nicotine pouches could provide a lower-risk alternative to traditional smokeless tobacco or combustible products for those looking to switch.⁶ However, the introduction of nicotine pouches to the market also could cause public health harm especially if pouches are being used by nicotine naive individuals. In 2021, the rates of lifetime and past-30-day pouch use among American high school students observed within the National Youth Tobacco Survey were 3.0% and 1.1%, respectively.⁷ However, higher rates of nicotine pouch use have been observed in studies that include high school-age and young adult participants. For example, the Truth Initiative reported that 13% of 15–24 year-olds reported past-30-day pouch use in Fall 2020.⁸

Similar to e-cigarettes (“vapes”), nicotine pouches may be appealing because they are available in a variety of flavors (e.g. citrus, mint) and can be used discreetly.¹ Their appeal may also be related to how they are marketed. Retailers often market nicotine pouches as “satisfying,”⁹ “clean(er),”⁹ “fresh,”⁹ “sweet,”¹⁰ and “intense.”¹⁰ While each of these claims may influence risk perceptions and use intentions, here we focus on claims about pouches being “tobacco-free.” Because nicotine pouches as a product class do not contain tobacco leaves, all nicotine pouches are tobacco leaf-free. However, until recently nicotine pouches all contained tobacco-derived nicotine (TDN). Now, several brands of nicotine pouches that contain synthetic nicotine have entered the market (e.g. Juice Head Pouches, 2ONE), and these brands use the term “tobacco-free nicotine” (TFN) to describe the nicotine in them. There is concern that the use of the term TFN may increase product appeal based on research showing that the term decreases young adults’ risk perceptions and increases use intentions for TFN e-cigarettes.¹¹ However, no research has examined the impact of describing nicotine pouches as containing “tobacco-free nicotine” on product perceptions, susceptibility, or use.

In the current study, we aimed to fill these gaps by surveying U.S. young adults (ages 18–25 years) about their awareness of, susceptibility to, and use of TFN pouches. To examine how the use of the term TFN may impact product risk perceptions and appeal, we also assessed comparative product perceptions for TFN versus TDN pouches. Finally, we examined how demographic characteristics, use of various nicotine products, and product perceptions were associated with awareness of, susceptibility to, and use of TFN pouches.

We tested three hypotheses. First, we expected that participants who had ever heard of, were susceptible to, or had used TFN pouches would be more likely to perceive TFN pouches as safer or otherwise better than TDN pouches. This was based on research suggesting that the term TFN reduces young adults’ risk perceptions and increases use intentions when it is applied to e-cigarettes.¹¹ Second, we hypothesized that young adults who had used smokeless tobacco would be more likely to report hearing about, being susceptible to, or using TFN pouches. This was based on prior work showing that most adults who use nicotine pouches currently use or previously used smokeless tobacco³ and the potential appeal of “tobacco-free” products to those aiming to quit using traditional tobacco products (e.g. users of smokeless tobacco or combustible tobacco products wishing to switch to pouch use). Third, we expected males to be more likely than females to report ever hearing about, being susceptible to, or using TFN pouches based on research showing that males are more likely to use both smokeless tobacco¹² and nicotine pouches (as a product class).^3,13 Given the novelty of the study, no other a priori hypotheses were made.

Methods

Participants and Procedure

From September through October 2021, 1239 U.S. young adults ages 18–25 years completed a 20-minute, anonymous Qualtrics^TM panels survey. Participants were recruited and compensated directly by Qualtrics Online Sample, a secure market research service operated by Qualtrics, Inc. Based on the aims of the larger parent study, which was designed to examine risk perceptions about tobacco-free nicotine e-cigarettes, we purposefully over-recruited current nicotine product users (especially e-cigarette users). Ultimately, participants were categorized into four tobacco use groups based on past-30-day use patterns: No tobacco product use (n = 365), exclusive e-cigarette use (n = 334), exclusive use of a tobacco product(s) other than e-cigarettes (n = 206), and use of both e-cigarettes and other tobacco products (n = 334).

To reduce participant burden, a subset of the total sample (n = 630; 50.8%) was randomized to complete the questions of relevance to the current analyses. Specifically, participants were provided with the following definition of TFN pouches prior to answering additional questions about them: “Nicotine pouches are small, white, pre-portioned pouches that you put in your mouth and tuck between your cheek and your gums. While no nicotine pouches contain any actual tobacco or tobacco leaves, until recently, all nicotine pouches contained purified nicotine that originally came from tobacco plants (i.e. tobacco-derived). Now, some nicotine pouches are “tobacco-free.” The nicotine in pouches that truly are “tobacco-free” is synthetic or artificial, meaning that it is created in a lab from chemicals that do not come from tobacco plants. For the questions that follow, “tobacco-free” refers to pouches that contain synthetic (artificial) nicotine.” Participants were given examples of TFN pouches (i.e. Niin, Fre, Rush, and 2One).

Participants then reported on perceptions associated with TFN pouches versus TDN pouches (all items are included in Table 2). Product perception items were based on content from the Smokeless Tobacco Expectancies Scale¹⁴ (e.g. gum disease, addiction, and teeth discoloration) and claims commonly made by nicotine pouch manufacturers (e.g. good flavors, clean taste, and smooth taste). Each perception item was scored on a five-point scale (i.e. strongly disagree, somewhat disagree, neither disagree nor agree, somewhat agree, and strongly agree). To assess product awareness, participants were asked “Before today, had you ever heard of tobacco-free nicotine pouches?” (no or yes). Participants who had previously heard of TFN pouches were asked if they had “ever used a tobacco-free nicotine pouch” (no or yes). Finally, participants who had not heard of or used a TFN pouch reported on susceptibility (“At any time in the next year, do you think you will use a tobacco-free nicotine pouch?” [definitely not, probably not, probably yes, and definitely yes]). Participants were coded as susceptible if they answered anything other than “definitely not.”¹⁵

Table 2.

Product Perceptions For Tobacco-Free Nicotine Pouches Versus Tobacco-Derived Nicotine Pouches

Compared to nicotine pouches that contain nicotine from the tobacco plant (i.e. tobacco-derived), tobacco-free nicotine pouches…		Tobacco-free versus tobacco-derived nicotine pouches (n = 630)
		Ever heard of tobacco-free nicotine pouches			Ever used tobacco-free nicotine pouches			Susceptible to tobacco-free nicotine pouches
		M	SD	p	M	SD	p	M	SD	p
Are less harmful to a person’s health	No	2.39	1.11	*	2.47	1.11		2.30	1.10	***
	Yes	2.60	1.11		2.46	1.14		2.83	1.04
Are less harmful to a person’s heart	No	2.42	1.04		2.47	1.06		2.34	1.08	***
	Yes	2.57	1.10		2.58	1.06		2.74	0.96
Are less addictive	No	2.39	1.10		2.45	1.11		2.27	1.07	***
	Yes	2.52	1.12		2.08	1.06		2.87	1.09
Are less expensive	No	2.74	0.87	**	2.80	0.91	**	2.72	0.91	***
	Yes	2.97	1.01		3.42	1.18		2.99	0.88
Are easier for a person my age to purchase	No	2.85	0.95		2.91	0.99		2.83	1.00	*
	Yes	3.00	1.08		3.00	1.22		3.06	0.95
Taste less like tobacco	No	2.96	0.92		3.01	0.96		2.97	0.94
	Yes	3.11	1.07		3.29	1.37		3.06	0.98
Taste smoother	No	2.81	0.86	*	2.88	0.95		2.79	0.91	**
	Yes	3.00	1.11		2.92	1.32		3.04	0.99
Have flavors that taste better	No	2.88	0.91		2.93	0.97		2.87	0.95	*
	Yes	3.02	1.11		3.13	1.42		3.05	0.98
Taste cleaner	No	2.81	0.91	*	2.86	0.96		2.79	0.94	*
	Yes	2.98	1.08		2.96	1.43		2.99	0.95
Have more of a chemical taste	No	2.98	0.94		3.02	0.96		3.00	0.94
	Yes	3.13	1.04		3.42	1.28		3.06	1.01
Taste better	No	2.88	0.92		2.92	0.96		2.85	0.93	*
	Yes	2.97	1.10		2.79	1.50		3.06	0.99
Are less likely to stain your teeth	No	2.59	1.14	*	2.67	1.17		2.58	1.18	*
	Yes	2.81	1.22		2.58	1.32		2.84	1.12
Are less harmful to a person’s mouth or gums	No	2.36	1.12	*	2.44	1.17		2.32	1.17	***
	Yes	2.56	1.25		2.17	1.24		2.69	1.11
Average Product Perceptions	No	2.70	0.62	**	2.83	0.60	**	2.66	0.64	***
	Yes	2.86	0.67		3.43	0.62		2.94	0.60

^* p < .05

^** p < .01

^*** p < .001 Heard of Tobacco-free Nicotine Pouches (yes = 235); Used Tobacco-free Nicotine Pouch (yes = 24); Susceptible to Tobacco-free Nicotine Pouches (yes = 174). Each perception item was scored on a five-point scale: strongly disagree, somewhat disagree, neither disagree nor agree, somewhat agree, and strongly agree.

Additional Measures

Tobacco Product-Related Screening Questions

Participants reported lifetime use of a variety of nicotine products (no or yes): disposable pod vape, e-hookah, cig-a-like, vape pen, JUUL, a rechargeable pod device other than JUUL, Mod or APV, hookah, cigar or cigarillo, smokeless tobacco, and nicotine pouch. Brief descriptions and a photo accompanied each product. To capture the broader product category of nicotine pouches irrespective of their nicotine source (i.e. TFN or TDN), the initial definition provided to participants was as follows: “Nicotine Pouch like Zyn, Velo, Niin, or On! (contains nicotine NOT tobacco leaves).”

Participants endorsing lifetime use of a given product reported on past-30-day use. Past-30-day use was used to fill the four tobacco product use quotas described above for the purposes of the larger parent study (i.e. no current use, exclusive e-cigarette use, exclusive use of a tobacco product other than e-cigarettes, dual use of e-cigarettes, and other tobacco products). Please note that all analyses presented in the current study focus on lifetime use.

Demographics

Participants reported on age (in years), biological sex (female or male), Hispanic ethnicity (no or yes), and race (white, black, Asian, American Indian or Alaska Native, Pacific Islander or Native Hawaiian, and Other [write-in]). Participants also reported on their subjective financial situation¹⁶ as an index of socioeconomic status (responses: I don’t meet basic expenses, I just meet basic expenses, I meet needs with a little left over, and I live comfortably).

Analytic Plan

First, we ran descriptive statistics on all study variables. Next, we ran a series of unadjusted independent samples t-tests to compare product perceptions for TFN versus TDN pouches within the following groups: ever heard of TFN nicotine pouches, susceptible to using TFN pouches, used TFN pouches (all coded no or yes). Although numerous comparisons were made, we chose not to adjust the alpha value for statistical significance (i.e. retained < .05) because we felt that it was not possible to value Type I over Type II error (or visa versa) given the novelty of the research questions.

In addition, because there was overlap in the items used to assess product perceptions, we ran a factor analysis to determine if the items could be scored on a unidimensional scale. The analysis supported unidimensional scoring (Supplementary Table 1), so scale scores were entered as an independent variable in the binary logistic regression models described below.

Finally, we ran three binary logistic regression models where participant demographics (i.e. age sex, Hispanic ethnicity, race, and subjective financial status); lifetime use of e-cigarettes, cigarettes, hookah, cigars or cigarillos, and smokeless tobacco; and the scale score for product perceptions of TFN versus TDN pouches were included as predictors of the following outcomes: Ever heard of TFN pouches, susceptible to using TFN pouches, and ever used TFN pouches (each coded as no or yes).

Results

Full descriptive statistics are presented in Table 1. However, in brief, participants were on average 21.15 years old (SD: 2.32) and 52.1% female. 33.5% of the sample reported Hispanic ethnicity, and 57.5% indicated White as their race. The rates of product awareness (37.3%) and susceptibility (29.2%) were considerable, while the rate of use was modest at 3.8%. However, among the 9.7% of participants who reported using any type of nicotine pouch, 39.3% reported using a tobacco-free nicotine pouch.

Table 1.

Descriptive Statistics

	Mean (SD) or Percent
Sample size	n = 630
Age	21.15 (2.32)
Female sex	52.1
Hispanic	33.5
White	57.5
Black	28.1
Asian	10.3
American Indian	4.6
Pacific Islander	1.9
Race other	2.7
Subjective financial status	2.51 (1.01)
Lifetime product use
E-cigarettes	74.4
Cigarette	44.8
Hookah	30.3
Cigar or Cigarillo	38.4
Smokeless tobacco	11.4
Any nicotine pouch	9.7
Tobacco-free nicotine pouches
Awareness	37.3
Ever used (total sample)	3.8
Ever used (amonglifetime users of any nicotine pouches)	39.3
Susceptible	29.2
Average product perceptions (Tobacco-Free vs. Tobacco-Derived)	2.75 (0.65)

Scoring for Subjective Financial Status (1= I don’t meet basic expenses, 2 = I just meet basic expenses, 3 = I meet needs with a little left over, and 4 = I live comfortably; range 1–4); Awareness (percentage of participants who had heard of tobacco-free/synthetic nicotine pouches); Susceptible (percentage of participants who had never used a tobacco-free nicotine pouch but who were susceptible to future use); AverageProduct Perceptions reflects the average score comprising all risk and appeal items (range 1 [strongly disagree] –5 [strongly agree]).

With regard to unadjusted findings (Table 2), significant between-group differences were observed for each product perception except “TFN pouches taste less like tobacco than TDN pouches” and “TFN pouches have more of a chemical taste than do TDN pouches.” Compared to participants who had never heard of TFN pouches, those who were aware of TFN pouches held stronger perceptions that, compared to TDN pouches, TFN pouches are less expensive (p < .01) and taste smoother, taste cleaner, are less likely to stain one’s teeth, and are less harmful to a person’s mouth or gums (p-values < .05). Compared to participants who had never used TFN pouches and were not susceptible to TFN pouches, those who were susceptible to TFN pouch use held stronger perceptions that TFN pouches are less harmful to a person’s health, less harmful to a person’s heart, less addictive, less expensive, and less harmful to a person’s mouth or gums (p-values < .001); taste smoother (p < .01); and taste cleaner, taste better, are easier for a person their age to purchase, and are less likely to stain one’s teeth (p-values < .05). Finally, compared to participants who had never used TFN pouches, those who had used TFN pouches held stronger perceptions that TFN pouches are less expensive than are TDN pouches (p < .01).

With regard to adjusted relationships (Table 3), the binary logistic regression models containing the scale score for TFN versus TDN pouch perceptions, participant demographics, and nicotine product use revealed that individuals who had heard of TFN pouches were more likely to be younger (OR_adj = 0.91), use cigarettes (OR_adj = 1.52), use cigars or cigarillos (OR_adj = 1.76), and hold stronger perceptions that TFN pouches are safer or better than TDN pouches (OR_adj = 1.48). Individuals who were susceptible to TFN pouch use were more likely to be male (OR_adj = 1.73), use e-cigarettes (OR_adj = 2.33), use cigarettes (OR_adj = 1.71), use smokeless tobacco (OR_adj = 2.32), and hold stronger perceptions that TFN pouches are safer or better than TDN pouches (OR_adj = 2.21). Finally, individuals who had used TFN pouches were more likely to be male (OR_adj = 2.97), white (OR_adj = 3.44), and use smokeless tobacco (OR_adj = 6.19).

Table 3.

Predictors of Ever Hearing About, Using, or Being Susceptible to Using Tobacco-Free Nicotine Pouches

	Ever heard of tobacco-free nicotine pouches						Ever used tobacco-free nicotine pouches						Susceptible to tobacco-free nicotine pouches
	B	S.E.	Wald	OR	95% CI		B	S.E.	Wald	OR	95% CI		B	S.E.	Wald	OR	95% CI
Age	−0.10	0.04	6.15	0.91*	0.84	0.98	−0.13	0.11	1.59	0.88	0.71	1.08	−0.02	0.04	0.16	0.98	0.90	1.07
Male Sex	−0.07	0.18	0.15	0.93	0.66	1.33	1.09	0.56	3.84	2.97*	1.00	8.81	0.55	0.20	7.40	1.73**	1.17	2.57
Hispanic	−0.05	0.19	0.07	0.95	0.65	1.39	0.41	0.49	0.71	1.51	0.58	3.95	−0.23	0.23	1.03	0.80	0.51	1.24
Race
White	0.16	0.26	0.36	1.17	0.70	1.95	1.24	0.58	4.53	3.44*	1.10	10.75	−0.63	0.31	4.27	0.53	0.29	0.97
Black	−0.01	0.28	0.00	0.99	0.57	1.73	—	—	—	—	—	—	−0.03	0.32	0.01	0.97	0.51	1.82
Asian	−0.32	0.33	0.95	0.72	0.38	1.39	—	—	—	—	—	—	−0.13	0.37	0.12	0.88	0.43	1.82
American Indian	−0.06	0.42	0.02	0.94	0.41	2.13	—	—	—	—	—	—	0.07	0.46	0.02	1.07	0.44	2.63
Pacific Islander	−0.41	0.71	0.33	0.67	0.16	2.69	—	—	—	—	—	—	−0.28	0.75	0.14	0.76	0.17	3.29
Other Race	0.49	0.52	0.86	1.62	0.58	4.53	—	—	—	—	—	—	−0.73	0.71	1.06	0.48	0.12	1.93
Financial Status	0.10	0.09	1.42	1.11	0.94	1.31	−0.16	0.23	0.49	0.86	0.55	1.33	0.09	0.10	0.89	1.10	0.91	1.33
Tobacco Product Use
E-cigarette	0.14	0.22	0.42	1.15	0.75	1.75	0.76	0.80	0.89	2.13	0.44	10.28	0.84	0.26	10.43	2.33**	1.39	3.88
Cigarette	0.42	0.20	4.50	1.52*	1.03	2.24	−0.07	0.59	0.02	0.93	0.29	2.93	0.53	0.22	5.80	1.71*	1.10	2.63
Hookah	−0.19	0.21	0.79	0.83	0.55	1.25	−0.07	0.54	0.02	0.93	0.33	2.65	−0.10	0.23	0.17	0.91	0.57	1.44
Cigar or Cigarillo	0.56	0.20	7.95	1.76**	1.19	2.60	0.84	0.56	2.28	2.31	0.78	6.87	0.27	0.22	1.50	1.31	0.85	2.03
Smokeless Tobacco	0.30	0.28	1.12	1.35	0.77	2.36	1.82	0.54	11.56	6.19**	2.16	17.69	0.84	0.34	6.17	2.32*	1.19	4.51
Product Perceptions	0.39	0.14	7.92	1.48**	1.13	1.95	0.11	0.34	0.10	1.11	0.57	2.18	0.79	0.17	21.34	2.21***	1.58	3.09

*p < .05

**p < .01

***p < .001 Ever Heard of Tobacco-free Nicotine Pouches (yes = 235)

Ever Used Tobacco-free Nicotine Pouch (yes = 24); Susceptible to Tobacco-free Nicotine Pouches (yes = 174). — given the limited sample size of nonwhite participants who had ever used a tobacco-free nicotine pouch, other race variables could not be included in the model. The variable product perceptions reflects the average score for each of the product perception items comparing tobacco-free and tobacco-derived nicotine (TDN) pouches.

Discussion

The current study is the first of which we are aware to examine young adults’ awareness of, susceptibility to, and use of TFN pouches that contain synthetic nicotine instead of TDN. In addition, the study uniquely examined comparative risk perceptions for TFN versus TDN pouches.

In our sample, the rate of TFN nicotine pouch awareness (37.3%) was identical to what was observed in a prior study of adults ages 18–29 years who smoke cigarettes (37.3%).¹⁷ In terms of pouch use, the rate of using any nicotine pouches in our sample (9.7%) also similar to the rate of 8.4% observed in the prior study of adults who smoked cigarettes.¹⁷ With regard to TFN pouches specifically, rates of TFN pouch use were 3.8% within the total sample and 39.3% among lifetime users of any nicotine pouch. Given the lack of prior research on TFN pouches, there are no studies of which we are aware to compare use rates. Of concern, the rate of susceptibility observed in our study (29.2%) was higher than what was observed among adults ages 18–44 years who smoke cigarettes (16.6%).¹⁷ Of note, the rate of susceptibility was not specified for the youngest age group (i.e. 18–29 years) in the prior published study of adults who smoke,¹⁷ so it is possible that the rates of susceptibility may align more closely or maybe more discrepant.

When considering comparative product perceptions, the bulk of the unadjusted between-groups differences were observed based on awareness of and susceptibility to TFN pouch use, respectively. In each case, young adults who had heard of or who were susceptible to TFN pouches perceived TFN pouches to be less harmful or better than TDN pouches. Of note, individuals who were aware of TFN pouches and those who were susceptible to TFN pouch use were disproportionately more likely to perceive TFN pouches to taste smoother and cleaner than TFN pouches. In addition, susceptible individuals also perceived TFN pouches as tasting better than TDN pouches. These perceptions map onto marketing claims that TFN pouches are natural, cleaner, smoother, and taste better⁹ and suggest that these types of marketing claims may be reaching and impacting young adults’ product perceptions. Furthermore, those who had heard of TFN pouches and who were susceptible to TFN use perceived reduced health-related harms of TFN pouches relative to TDN pouches, suggesting that the term TFN is impacting young adults' perceptions related to health and addiction. Additional research is needed to determine whether there are perceptible differences in taste between TFN and TDN products and whether TFN and TDN have similar impacts on health and addiction risk. If TFN products are confirmed to taste better and confer less risk for addiction and harm than TDN products, participant perceptions would be considered accurate. However, if TFN products are not associated with better taste than TDN products or if TFN products are found to confer comparable or increased health harms compared to TDN, this would provide evidence that the term TFN could be conveying inaccurate perceptions about reduced risk.

With regard to unadjusted relationships by TFN pouch use status, lifetime TFN pouch users disproportionately perceived TFN pouches to be less expensive than TDN pouches. The lack of additional significant findings may reflect the small number of participants (n = 24) who had used TFN pouches, and additional research is needed with a larger sample of TFN pouch users. However, the finding regarding perceived differences in price between TFN and TDN pouches merits note as this also was observed for awareness and susceptibility; those who were aware of or susceptible to TFN pouch use perceived TFN pouches to be less expensive than TDN pouches. An internet search conducted by our team revealed that nicotine pouches as a product category are less expensive than smokeless tobacco in many states (the focus of a separate study). However, TFN and TDN pouches are comparably priced. Therefore, the perception that TFN pouches are less expensive than TDN pouches requires additional exploration.

With regard to adjusted associations, stronger perceptions that TFN pouches are safer or otherwise better than TDN pouches were significantly associated with both TFN pouch awareness and susceptibility. These findings suggest that the term TFN may reduce risk perceptions and increase the appeal of nicotine pouches, similar to what was observed for TFN e-cigarette susceptibility in young adults.¹¹ All the remaining significant findings for TFN awareness, susceptibility, and use, respectively, were related to participant demographics and nicotine product use.

Young adults who were lifetime cigarette users were more likely to be aware of or susceptible to TFN pouches. While these relationships need further investigation, relatively high rates of product awareness (29.2%) and a link between interest in quitting smoking cigarettes and interest in trying nicotine pouches have been documented among adult cigarette smokers.¹⁷

Young adults who were male and who used smokeless tobacco were more likely to be susceptible to or to have used TFN pouches. These findings align with prior research showing that males are more likely than females to use smokeless tobacco¹² and nicotine pouches;^3,13 smokeless tobacco users may be particularly drawn to nicotine pouch use because of the overlap in product features³; and traditional smokeless tobacco use is associated with ever hearing about nicotine pouches (as a product class) among adult cigarette smokers.¹⁷ Although we did not assess motivations for use or interest in product switching, the term “tobacco-free” also may appeal to smokeless tobacco users who are interested in switching to TFN pouches as a means of reducing harm and living a “tobacco-free” lifestyle.

Younger individuals were more likely to be aware of TFN pouches, consistent with research linking pouch awareness to younger age among adult cigarette smokers.¹⁷ In addition, individuals who used cigars or cigarillos were more likely to be aware of TFN pouches, although additional research is needed to explore the relationship between cigar and cigarillo use and pouch awareness. With regard to susceptibility, young adults who used e-cigarettes were more likely to be susceptible to TFN pouch use. This finding is intriguing as e-cigarette use was not associated with TFN pouch awareness or use, but it could be linked to the fact that both e-cigarettes and nicotine pouches are available with TFN. Finally, white participants were more likely to have used TFN pouches, although this finding may be specific to the United States; a study from the United Kingdom found that nonwhite individuals were more likely to have tried nicotine pouches.¹³

The study findings must be considered along with their limitations. Data were collected from a convenience sample of young adult Qualtrics panelists from the United States, which may limit generalizability. Also, data on geographical location were not collected in this survey, so relationships between regions of the country and the outcomes of interest could not be examined. In addition, given that we purposefully oversampled current e-cigarette and other tobacco product users, rates of use of all nicotine products were not representative of the broader population and therefore cannot be considered prevalence estimates. However, given that no quotas were set specifically based on nicotine pouch use (TFN or as a general product class), the observed use rates may be relatively representative of subpopulations of young adults who use e-cigarettes and other tobacco products. That said, given that the rates of lifetime use of nicotine pouches and TFN pouches, specifically, were relatively modest, our analyses were limited to focusing on lifetime use. Related, statistical power for detecting effects was very limited for the model predicting TFN pouch use given the small number of TFN pouch users and the limited sample sizes for each of the model covariates. In addition, we explicitly compared TFN pouches to TDN pouches. However, the term “tobacco-derived nicotine” generally is not included on nicotine pouch packaging. As such, future research is needed to directly evaluate the impact of including the label “tobacco-free nicotine” on nicotine pouch packaging versus typical packaging (e.g. “nicotine pouches”) to better approximate real-world impact. In addition, we did not specifically evaluate the use of TDN pouches, so additional research is needed to clarify whether participant factors associated with TFN pouch use are similar to or distinct from those associated with TDN pouch use. Finally, there may have been some confusion about what brands constitute tobacco-free versus TDN pouches given that some companies (e.g. Zyn) have advertised their tobacco-derived products as tobacco-free in the past. To help mitigate this issue, we purposefully gave examples of tobacco-derived and tobacco-free nicotine pouches in the question assessing the use of any pouches (i.e. Nicotine Pouch like Zyn, Velo, Niin, or On!) and limited our examples to products containing synthetic nicotine (i.e. Niin, Fre, Rush, and 2One) in the questions assessing awareness of, susceptibility to, and use of tobacco-free nicotine pouches. In addition, although the data were not included in the current study, we asked participants to indicate brands of tobacco-free nicotine pouches they had heard of. Of the 235 participants who indicated that they had heard of tobacco-free (synthetic) nicotine pouches, only 8 (3%) incorrectly indicated a tobacco-derived brand (e.g. Zyn, Velo, and On). Finally, of the 9.7% of participants who indicated lifetime use of any pouch, 39.3% indicated lifetime use of a tobacco-free nicotine pouch, suggesting that young adults are differentiating between synthetic and TDN pouch products.

In closing, the current study adds to the very limited literature on oral nicotine pouches, with a specific focus on TFN versus TDN pouches. Although the rate of TFN pouch use was low in our sample, rates of TFN pouch awareness and susceptibility were higher than what was observed for the general product class (i.e. all nicotine pouches) among adults who smoke cigarettes.¹⁷ Importantly, stronger perceptions that TFN pouches are safer or otherwise better than TDN pouches were associated with TFN pouch awareness and susceptibility in adjusted models, which could translate to experimentation with pouches that are advertised as being “tobacco-free” or containing “synthetic nicotine” in the future. Longitudinal research is needed to examine the extent to which TFN pouch awareness and susceptibility translate into future product use, and it will be important to track the characteristics of individuals who begin using TFN pouches. For instance, if TFN pouches lead current smokeless or combustible tobacco product users to switch to exclusive pouch use, this could improve public health. However, if TFN pouches are adopted by tobacco-naïve individuals or increase overall nicotine exposure via dual use with other nicotine products, this would harm public health. Additional research on the safety and flavor profile of TFN versus TDN pouches is also needed before it will be possible to evaluate whether the term TFN is misleading or not. In the meantime, ongoing monitoring of TFN (and TDN) pouch use is needed to inform potential future regulatory efforts by the FDA, which gained regulatory authority over synthetic nicotine products in March 2022.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

Efforts by Drs. Morean, Bold, Davis, Kong, Krishnan-Sarin, and Camenga were supported by grant number 20YVNR35460041 from the American Heart Association. Efforts for the study team also were supported by grant number U54DA036151 from the National Institute on Drug Abuse of the National Institutes of Health and the Center for Tobacco Products of the U.S. Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Heart Association, the National Institutes of Health, or the U.S. Food and Drug Administration.

Declaration of Interests

Drs. Morean, Bold, Davis, Kong, Krishnan-Sarin, and Camenga have no conflicts of interest to declare related to the current study.

Data Availability

Data will be made available upon reasonable request to the corresponding author, Meghan Morean, PhD (meghan.morean@yale.edu).