Prevalence of and Disparities in Adolescents’ Susceptibility to Novel Oral Nicotine Products Marketed as “Tobacco-Free”

Abstract

Non-therapeutic, novel oral nicotine products are convenient, discreet to use, and flavored, with increasing sales in the United States. It is unclear whether these products appeal predominantly to adolescents already susceptible to inhalable nicotine products, or whether they attract adolescents who would not otherwise use nicotine. This study examined prevalence and correlates of susceptibility to inhalable and oral nicotine product use among adolescents. Ninth- and tenth-grade students from Southern California who had never used any nicotine product (N=3,129) completed an online survey in Fall 2021 assessing susceptibility to inhalable (i.e., cigarettes, e-cigarettes) and oral (e.g., pouches, gum, gummies) nicotine products. Multinomial logistic regression analyses estimated associations of demographic characteristics with odds of susceptibility to oral, inhalable, or both products. Susceptibility was highest for e-cigarettes (19.7%), followed by cigarettes (15.0%) and nicotine gum, lozenges, tablets and/or gummies (15.0%), and nicotine pouches (8.7%). Dual susceptibility to oral and inhalable products (vs. neither product type) was higher in cisgender female and non-cisgender (vs. cisgender male) adolescents (odds ratios [ORs]=1.36-2.02; ps<0.05). Hispanic adolescents (vs. Asian) were more susceptible to both products (OR=1.47; p<0.05). Lower-socioeconomic status (SES) and sexual minority adolescents were more susceptible to oral (ORs=1.76-1.87; ps<0.05) and both products (ORs=1.32-1.88; ps<0.05), compared to higher-SES and heterosexual adolescents. Adolescents in Southern California may be more susceptible to e-cigarettes than other nicotine/tobacco products. However, appreciable numbers may be susceptible to oral nicotine products, including some youth who might not otherwise use nicotine and youth from populations historically impacted by tobacco-related health disparities.

INTRODUCTION

The tobacco industry has contributed to tobacco use disparities by targeting specific demographic populations. Marketing tactics have included representation of targeted populations in marketing, selective product placement in targeted neighborhoods, price promotions to increase product accessibility, and donations to community organizations.^1,2 Tobacco use prevalence is disproportionately high in lower-socioeconomic status (SES), sexual and gender minority, and some racial/ethnic minority (e.g., American Indian/Alaska Native, multiracial) adult populations.^1,3 Disparities in tobacco product use could be exacerbated by new non-combustible tobacco products. Disparities by sexual and gender identity,⁴ including disparities in e-cigarette use,⁵ emerge in adolescence. Moreover, use of e-cigarettes has increased among younger populations and minoritized racial/ethnic groups.⁶ To guide regulatory decision-making and prevent newer products from exacerbating longstanding disparities, it is important to understand adolescents’ susceptibility to emerging nicotine and tobacco products.

Susceptibility to nicotine use, defined as the absence of firm resolve not to use nicotine products, reflects an individual’s curiosity about, intention to use, and willingness to use nicotine-containing products under specific social circumstances. Social influence may prompt tobacco use even in the absence of intention to use tobacco, for those without firm resolve to abstain.⁷ Longitudinal studies have demonstrated that youth who are susceptible to nicotine products are significantly more likely to initiate use.^8–10 Longitudinal studies conducted in the 1980s and 1990s found that adolescents who were susceptible to smoking cigarettes at baseline were more likely than their non-susceptible peers to have initiated smoking 1-4 years later. Susceptibility predicted smoking initiation above and beyond other known risk factors such as peers’ smoking and access to cigarettes.^8,10 Subsequent research with adolescents in 2014-2016 found that susceptibility to each of four tobacco products predicted use of that product 16 months later, suggesting that susceptibility measures can be adapted for different products.⁹ Thus, susceptibility may be a good marker of the relative risk of use of specific nicotine and tobacco products in the coming years.

E-cigarettes are currently the most commonly used nicotine/tobacco products among adolescents.¹¹ However, non-therapeutic, novel oral nicotine products (i.e., nicotine pouches, gum, lozenges, tablets, and gummies; hereafter referred to as “oral nicotine products”) possess features that may appeal to adolescents. These products are available in flavors, such as coffee,¹² red mango,¹³ and cherry bomb,¹⁴ and can be used discreetly, as oral nicotine products do not produce aerosol that can be seen or smelled. Although similar in form to some nicotine replacement therapy products (e.g., therapeutic gum, lozenges), the majority of new oral nicotine products are not regulated or marketed as medicinal smoking cessation aids. They are often marketed as “tobacco-free,”¹² a marketing claim that can falsely suggest safe use to young people.¹⁵ Advertisements emphasize the products’ discreetness, convenience, and lack of stigmatizing byproducts of tobacco use (e.g., spit, smoke).¹⁶ Packaging for oral nicotine products is often colorful, and websites for certain brands of nicotine gummies and gums state their products “taste and feel amazing.”^13,14 Sales of nicotine pouches at convenience stores have risen substantially,¹⁷ and more money is now spent advertising emerging oral nicotine products than traditional smokeless tobacco products in the U.S.¹⁸

Youth who are not susceptible to inhalable tobacco products, such as cigarettes and e-cigarettes, may still be susceptible to oral nicotine products. Oral nicotine products are easy to use, discreet, and often resemble typical chewing gum, gummy candy, and breath mints (i.e., tablets) that youth already know how to use. They do not produce noticeable odor, smoke, or aerosol. On the other hand, inhalable tobacco products (e.g., cigarettes, e-cigarettes) share features that may reduce their appeal to youth. Inhalable products create noticeable smoke or vapor, decreasing the ability to conceal product use. Moreover, use of an inhalable product is unfamiliar for tobacco-naïve youth and often involves steps that are not intuitive (e.g., lighting a cigarette, pushing buttons on an e-cigarette device). To our knowledge, research has not yet examined whether specific characteristics of oral nicotine products appeal to youth. However, for tobacco-naïve youth, a product that resembles a typical edible non-nicotine product in both product appearance and packaging may feel more familiar and intuitive to use than a product that requires inhalation. Oral nicotine products may also be perceived as lower-risk than inhalable products. National public education campaigns, such as the United States (U.S.) Food and Drug Administration’s (FDA’s) The Real Cost campaign,¹⁹ have focused primarily on the harms of inhalable tobacco products. Youth may be unaware that new oral nicotine products also contain nicotine.

Oral nicotine products may reduce exposure to harmful and potentially harmful constituents compared to inhalable nicotine products, such as combustible cigarettes or e-cigarettes,²⁰ and may appeal to young adults who use inhalable nicotine products.^21,22 However, oral nicotine products are not safe for adolescent use. Youth are vulnerable to the dependence-producing effects of nicotine.²³ While premarket tobacco product applications for several oral nicotine products are currently under review,^24,25 oral nicotine products are available in retail locations around the U.S.²⁶ Prior to regulatory decision-making regarding the marketing of oral nicotine products, there is a pressing need to understand the extent to which youth are susceptible to using these products. However, little is known about the relative prevalence of youth susceptibility to oral nicotine products in the general population or in priority populations impacted by targeted marketing. As oral nicotine product sales increase, it is important to monitor susceptibility to these emerging products among youth from historically targeted populations. Oral nicotine product use is most prevalent among young adults,²⁷ and susceptible adolescents may initiate use when they reach young adulthood.

This study aimed to: a) examine adolescents’ relative prevalence of susceptibility to oral nicotine products compared to other nicotine/tobacco products, and b) compare prevalence of susceptibility of oral nicotine products (with and without susceptibility to inhalable products) between majority and minoritized populations. Due to the novelty of oral nicotine products, analyses were exploratory, without a priori hypotheses. High prevalence of susceptibility to oral nicotine products, especially among populations already affected by nicotine/tobacco use disparities, would indicate a need to protect youth through regulatory decision-making. In a cross-sectional analysis of a cohort of ninth and tenth grade students in Southern California who never used nicotine, we examined susceptibility to use of two types of novel oral nicotine products (i.e., pouches and non-therapeutic gum, lozenges, tablets, or gummies), and compared susceptibility to using oral products with susceptibility to using two types of inhalable products (i.e., e-cigarettes, combustible cigarettes). We calculated susceptibility prevalence estimates for each specific product. To examine oral nicotine products’ potential to exacerbate disparities, we compared odds of susceptibility to using oral products, inhalable products, or both products by participant SES, sexual and gender identity, and race/ethnicity.

METHODS

Participants and Procedure

Ninth-grade adolescents (N=3,625) were originally recruited from 11 high schools in Southern California from Fall 2020 to Fall 2021 to participate in an ongoing prospective cohort study of behavioral health. The data used in the current study were collected in Fall 2021 (September to December 2021), when students were in ninth (n=1,159) or tenth grade (n=2,465). Surveys were completed in-class. Students absent on the day of data collection were sent a survey link to complete outside of class. The analytic sample included participants who completed items measuring susceptibility to nicotine product use and had never used any nicotine/tobacco product (i.e., cigarettes, e-cigarettes, IQOS, dissolvable tobacco, cigars, cigarillos, hookah, e-hookah, nicotine pouches, or any flavored nicotine gum, lozenges, tablets, or gummies), yielding a final analytic sample of 3,129 participants. Study procedures were approved by the University of Southern California Institutional Review Board. Parents provided written informed consent and students provided written assent.

Measures

Susceptibility.

The primary outcome, susceptibility, was assessed for four nicotine products: a) combustible cigarettes, b) e-cigarettes, c) nicotine pouches, and d) any flavored nicotine gum, lozenges, tablets, and/or gummies. As in past research demonstrating the validity of susceptibility measures,^8,9 three items assessed susceptibility to using each of the four products: willingness to try the product if offered by a best friend, intention to use the product in the next year, and curiosity about the product (response options: definitely not, probably not, probably yes, definitely yes). Following guidelines for susceptibility measure scoring,⁸ participants who answered “definitely not” to all three items for the specific product were considered not susceptible; those who gave a response other than “definitely not” to any item were considered susceptible. Participants were further categorized into a mutually exclusive four-category variable: exclusive susceptibility to inhalable products (i.e., cigarettes and/or e-cigarettes), exclusive susceptibility to oral products (i.e., pouches and/or any flavored nicotine gum, lozenges, tablets, and/or gummies), poly-product susceptibility to both inhalable and oral products, or non-susceptibility to neither inhalable nor oral products.

Sociodemoqraphic characteristics.

Participants reported their gender identity as male/masculine, female/feminine, transgender male, transgender female, gender variant/non-binary, or another gender (categorized as cisgender male [male/masculine], cisgender female [female/feminine], or another gender). Race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, multi-ethnic or multi-racial, or another race) and Hispanic/Latinx ethnicity (yes or no) were assessed in two separate items. For analyses, race and ethnicity were then categorized as Hispanic, non-Hispanic Asian, non-Hispanic white, multiracial, or another race/ethnicity. Participants reported their family’s socioeconomic status, from birth to age 16, as: a) “pretty well off financially,” b) “about average,” c) “financially struggling or in poverty,” or d) “it varied.” For analyses, responses were categorized as “financially struggling” or “it varied” versus “pretty well off financially” or “about average.” Lastly, sexual identity was reported as straight/heterosexual, asexual, bisexual, gay, lesbian, pansexual, queer, questioning or unsure, another identity not listed, or not disclosed (categorized as straight/heterosexual vs. another sexual identity or questioning).

Statistical Analysis

We first calculated the percentage of participants classified as susceptible to combustible cigarettes, electronic cigarettes, nicotine pouches, and any flavored nicotine gum, lozenges, tablets, and/or gummies. To determine whether the oral nicotine product susceptibility measures psychometrically performed similarly to the more established cigarette and e-cigarette susceptibility measures,^8,9 response frequencies for each susceptibility item and correlations between items were examined for each product. Adjusted multinomial logistic regression analyses evaluated the association of each sociodemographic characteristic with susceptibility exclusively to inhalable products, exclusively to oral products, or to both inhalable and oral products, relative to susceptibility to neither inhalable nor oral products (outcome reference). The primary analysis tested multivariable regression models adjusting for multiple sociodemographic regressors simultaneously. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. The independence of irrelevant alternatives (IIA) assumption in multinomial logit models was evaluated with the Hausman test.²⁸ All models were tested in Mplus version 8²⁹ using the complex analysis function to adjust parameter standard errors for independence in the data due to nesting of students within schools. Significance was set to alpha = .05 (two-tailed). Missing data on sociodemographic characteristics were handled using a missing indicator approach. Racial/ethnic groups underrepresented in this sample (i.e., Black/African American, American Indian/Alaska Native, Native Hawaiian/Pacific Islander) are not reported in the multivariable regression model. Due to small cell sizes, these groups were combined with missing data using a missing indicator approach. Sensitivity analyses were conducted using listwise deletion instead of a missing indicator approach.

RESULTS

Participant Characteristics

Participant characteristics of the analytic sample are presented in Table 1. The sample was gender-balanced (46.5% cisgender female, 46.1% cisgender male, 4.5% another gender) and racially and ethnically diverse (44.9% Hispanic, 34.5% non-Hispanic Asian, 8.2% multiracial, 6.8% non-Hispanic white, 1.8% Black or Indigenous, and 1.4% another race/ethnicity). A majority reported their family’s financial status as “about average” (53.1%); 73.3% identified as heterosexual and 21.3% identified as another sexual identity, with 5.5% not reporting their sexual identity. Most participants (73.3%) were not susceptible to inhalable or oral product use; 12.7% were susceptible to both types of products, 11.1% were susceptible to inhalable products only, and 2.9% were susceptible to oral products only. Ninth and tenth graders did not significantly differ in their odds of susceptibility to inhalable products, oral products, or both, relative to non-susceptibility (p-values > .066). Missing sociodemographic data were minimal (gender: n=90 [2.9%]; race/ethnicity: n=79 [2.5%]; family’s socioeconomic status: n=50 [1.6%]; sexual identity: n=171 [5.5%]).

Table 1.

Participant characteristics among 3,129 adolescents in Southern California in Fall 2021 who have never used nicotine or tobacco

	% (n)
Gender
Cisgender male	46.1% (1443)
Cisgender female	46.5% (1454)
Another gender1	4.5% (142)
Unreported gender	2.9% (90)
Race/ethnicity
Hispanic	44.9% (1404)
Non-Hispanic Asian	34.5% (1079)
Multiracial	8.2% (256)
Non-Hispanic White	6.8% (212)
Non-Hispanic Black or Indigenous2	1.8% (55)
Another race	1.4% (44)
Unreported race	2.5% (79)
Family’s financial status 3
In poverty or it varied	16.6% (518)
Well-off or about average	81.8% (2561)
Unreported financial status	1.6% (50)
Sexual identity
Heterosexual	73.3% (2292)
Another sexual identity4	21.3% (666)
Unreported sexual identity	5.5% (171)

¹Includes transgender male or female (0.8%, n = 25) and non-binary (3.7%, n = 117)

²Includes non-Hispanic Black (n=47), non-Hispanic American Indian/Alaska Native (n=0), or non-Hispanic Native Hawaiian/Pacific Islander (n=8)

³In poverty (5.3%, n=165), it varied (11.3%, n = 353), well off (28.7%, n = 899), about average (53.1%, n = 1662), unreported (1.6%, n = 50)

⁴Includes sexual minorities (i.e., gay, lesbian, bisexual, queer, asexual, pansexual, or another sexual identity; 16.7%, n = 521), and questioning or unsure (4.6%, n = 145)

Descriptive Data on Adolescent Susceptibility to Using Specific Products

Table 2 shows the patterns of responses to each item in terms of each specific product’s susceptibility score (N = 3,129). Susceptibility was highest for e-cigarettes (19.7%), followed by cigarettes (15.0%) and nicotine gum, lozenges, tablets and/or gummies (15.0%), and lowest for nicotine pouches (8.7%); 15.6% were susceptible to oral nicotine products (i.e., gum, lozenges, tablets, gummies, and/or pouches). Response patterns were consistent across products. Within each product category, participants were most likely to endorse curiosity about use (6.3%-14.8%), followed by willingness to try the product if offered by a friend (5.2%-13.9%), and intention to use the product in the next year (4.1%-8.5%). Correlations between susceptibility survey items are presented in Supplemental Table 1. Correlations between binary items (i.e., susceptible versus non-susceptible) were similarly high for cigarettes (Φ = .54-.59; KR-20 value = .78), e-cigarettes (Φ = .58-.61; KR-20 value = .81), pouches (Φ = .53-.64; KR-20 value = .80), and gum, lozenges, tablets, and/or gummies (Φ = .54-.59; KR-20 value = .79).

Table 2.

Susceptibility to cigarettes, e-cigarettes, nicotine pouches, and nicotine gum, lozenges, tablets, and/or gummies (N=3,129)

	Try if friend offered	Use in the next year	Curious about use	Overall Susceptibility
	% (n) susceptible 1	% (n) susceptible 1	% (n) susceptible 1	% (n) susceptible to product 1
Cigarettes	8.8% (276)	5.5% (172)	12.0% (374)	15.0% (469)
E-Cigarettes	13.9% (435)	8.5% (267)	14.8% (462)	19.7% (617)
Nicotine pouches	5.2% (162)	4.1% (127)	6.3% (196)	8.7% (273)
Gum, lozenges, tablets, gummies 2	10.4% (325)	5.9% (185)	10.8% (337)	15.0% (469)

¹Response options for each item were “definitely not,” “probably not,” “probably yes,” and “definitely yes.” Any response other than “definitely not” indicated susceptibility.

²Includes any flavored nicotine gum, lozenges, tablets, and/or gummies

Prevalence and Demographic Correlates of Susceptibility to Inhalable and/or Oral Nicotine Products

Odds of susceptibility to inhalable and oral nicotine products by sociodemographic characteristics are presented in Table 3. Compared to cisgender male participants, cisgender female participants and participants of another gender were more likely to be exclusively susceptible to inhalable products (cisgender female: OR = 1.48, 95% CI [1.13, 1.94]; another gender: OR = 2.66, 95% CI [1.42, 4.98]) and poly-product susceptible to both oral and inhalable products (cisgender female: OR = 1.36, 95% CI [1.16, 1.59]; another gender: OR = 2.02, 95% CI [1.27, 3.23]), relative to no susceptibility to either product category. Odds of exclusive susceptibility to oral products (versus no products) did not significantly differ between genders or races/ethnicities. Compared to Asian youth, Hispanic youth were more likely to be susceptible to inhalable products only (OR = 1.45, 95% CI [1.13, 1.84]) and poly-product susceptible (OR = 1.47, 95% CI [1.15, 1.88]), relative to no susceptibility. Multiracial youth were more likely to be susceptible to inhalable products (OR =1.41, 95% CI [1.03, 1.94]) relative to no susceptibility than were Asian youth. Relative to no susceptibility, youth in poverty or with a financial status that varied were more likely to be susceptible to oral products only (OR = 1.76, 95% CI [1.05, 3.18]) and inhalable products only (OR = 1.49, 95% CI [1.08, 2.06]) than were youth who were well-off or average financially. Compared to heterosexual youth, sexual minority or questioning youth were more likely to be susceptible exclusively to oral products (OR = 1.87, 95% CI [1.02, 3.49]), exclusively to inhalable products (OR = 1.49, 95% CI [1.13, 1.97]), and to both types of products (OR = 1.88, 95% CI [1.44, 2.46]), versus no susceptibility.

Table 3.

Odds of susceptibility to inhalable and oral nicotine products vs. non-susceptibility to any product, by sociodemographic characteristics

	Susceptibility Adjusted OR (95% CI)
	Orals Only (vs. none)1 (n=92)	Inhalables Only (vs. none)2 (n=347)	Both (vs. none) (n=396)
Gender
Male	Ref	Ref	Ref
Female	0.94 (0.63, 1.40)	1.48 (1.13, 1.94)	1.36 (1.16, 1.59)
Another gender3	1.91 (0.84, 4.34)	2.66 (1.42, 4.98)	2.02 (1.27, 3.23)
Race/ethnicity 4
Non-Hispanic Asian	Ref	Ref	Ref
Hispanic	0.68 (0.39, 1.21)	1.45 (1.13, 1.84)	1.47 (1.15, 1.88)
Non-Hispanic White	0.77 (0.37, 1.62)	1.22 (0.65, 2.28)	1.24 (0.79, 1.96)
Multiracial	1.44 (0.75, 2.75)	1.41 (1.03, 1.94)	1.41 (0.92, 2.17)
Family’s socioeconomic status
Well-off or about average	Ref	Ref	Ref
In poverty or it varied	1.76 (1.05, 3.18)	1.49 (1.08, 2.06)	1.32 (0.93, 1.87)
Sexual identity
Heterosexual	Ref	Ref	Ref
Sexual minority or questioning	1.87 (1.02, 3.49)	1.49 (1.13, 1.97)	1.88 (1.44, 2.46)

Note: “Ref” indicates reference group for each characteristic. Odds ratios compare odds of susceptibility to each product category (i.e., oral products only, inhalable products only, both types of products) versus no susceptibility (n = 2,294). Participants with the characteristic were more likely (OR>1.0) or less likely (OR<1.0) than those without the characteristic to report susceptibility to the product category, relative to reporting no susceptibility to inhalable and/or oral nicotine products.

¹Oral products include nicotine pouches and any flavored nicotine gum, lozenges, tablets, and/or gummies.

²Inhalable products include cigarettes and e-cigarettes.

³Includes transgender male or female (0.8%, n = 25) and non-binary (3.7%, n = 117)

⁴Racial/ethnic groups underrepresented in this sample (i.e., Non-Hispanic Black/African American, American Indian/Alaska Native, Native Hawaiian/Pacific Islander) were combined with missing data and not reported here due to small cell sizes.

In the primary analysis, the IIA assumption was tested using the Hausman test, and adding or deleting alternative outcome categories did not affect the estimated parameters (i.e., ORs) between the full and restricted models (χ2/df ≤ 0.94, p-values ≤ .33). Using listwise deletion, the pattern of results described above was unchanged, except that lower-SES youth were no longer significantly more likely to be uniquely susceptible to oral products than were higher-SES youth (OR = 1.76, 95% CI [0.92, 3.39]).

DISCUSSION

Among a diverse sample of ninth and tenth grade students in Southern California who had never used nicotine, the percentage susceptible to use of any flavored nicotine gum, lozenges, tablets and/or gummies was equal to that of youth susceptible to cigarette smoking and slightly lower than e-cigarette use susceptibility prevalence. Youth of lower socioeconomic status and sexual minority youth were more likely than their peers to be susceptible to all nicotine products, including being susceptible to oral nicotine products in the absence of susceptibility to inhalable products. Results indicate that novel oral nicotine products could promote nicotine susceptibility in some youth who would not otherwise use inhalable nicotine, particularly youth from certain populations historically impacted by tobacco-related health disparities. Novel oral nicotine products could therefore exacerbate disparities in adolescents’ tobacco use prevalence and, long-term, in tobacco-related disease.

Among the three constructs comprising susceptibility (i.e., curiosity, willingness, and intention⁷), participants susceptible to oral nicotine product use were most likely to report curiosity about oral nicotine products and least likely to report intention to use in the next year. This is consistent with the conceptualization of the susceptibility uptake continuum that originates with curiosity, progresses to willingness and intention to use, and then terminates with actual use uptake.⁸ Similar patterns for individual susceptibility items were observed for e-cigarettes and combustible cigarettes, with strong correlations between items. In a previous study, product-specific susceptibility measures predicted initiation of cigarette, e-cigarette, hookah, and cigar/cigarillo use among youth with no history of tobacco use.⁹ Our findings indicate that validated susceptibility measures can likely be adapted for oral nicotine products as well. In this study, susceptibility prevalence was highest for e-cigarettes and lowest for nicotine pouches. Use prevalence in the same cohort followed a similar pattern,³⁰ further supporting the validity of the adapted susceptibility measure.

Despite having never used nicotine or tobacco products previously, 2.9% of participants were susceptible to oral nicotine products and not susceptible to inhalable products—a modest proportion, but non-negligible on a population scale. While inhalable products generate noticeable smoke or aerosol, oral nicotine products can be consumed just like typical gum, candy, or mints. Due to their convenience and ability to be used discreetly, oral nicotine products may have fewer deterrents to initiation than inhalable nicotine products, such as concerns about concealing use from parents and teachers. Among youth, initiating tobacco product use is associated with subsequent susceptibility to other tobacco products.³¹ Initiating use of oral nicotine products may similarly precede susceptibility to other products. Additionally, there is convergent evidence that youth use of other non-combustible forms of nicotine (i.e., e-cigarettes) precedes increased risk of initiating combustible cigarette smoking.³² Discreetness and ease of using oral nicotine products mirror characteristics of e-cigarettes, as high school students have been reported to use e-cigarettes in places where smoking and vaping are not allowed (i.e., “stealth vaping”), including during class time.³³ Similar to how some e-cigarettes resemble USB drives, many oral nicotine products appear as food products, particularly when stored outside their original packaging. Oral nicotine products might be easier than e-cigarettes for youth to possess and use. They may allow for increased nicotine exposure by enabling nicotine use throughout the day, which could increase nicotine dependence risk. Oral nicotine products do not contain solid tobacco, and some use synthetic nicotine instead of nicotine derived from tobacco or use of shredded tobacco leaves.³⁴ Effective April 14, 2022, synthetic nicotine falls under FDA’s regulatory authority as a tobacco product.³⁵ As this is a recent change, future research should examine how regulating sales and marketing of synthetic nicotine may affect youth uptake of oral nicotine products.

Disparities in susceptibility to oral nicotine product use were evident by socioeconomic status and sexual identity. Specifically, youth of lower SES and with sexual minority identities had elevated risk of susceptibility to inhalable products only, oral products only, or both products. The tobacco industry has a long history of targeting vulnerable groups with marketing, which has contributed to the high cigarette smoking prevalence observed among sexual minority and low-SES populations.¹ Disparities in tobacco use prevalence first emerge in adolescence. Prior research has identified disparities in tobacco product use (e.g., cigarettes, e-cigarettes, cigars, hookah) between sexual minority and heterosexual youth,^4,5,36 with greater disparities by sexual identity among females than males.^4,36 Additionally, a systematic review concluded that in high-income countries like the U.S., lower-SES youth are more likely to smoke cigarettes than are higher-SES youth.³⁷ Results of this study suggest that oral nicotine products may appeal to youth with no history of tobacco use from populations impacted by tobacco use disparities. Therefore, oral nicotine products have the potential to exacerbate tobacco use disparities. Although gender minority youth and Hispanic youth were not at elevated risk for unique susceptibility to oral nicotine products, they were more likely to be susceptible to both inhalable and oral products, compared to cisgender and Asian youth. If prevalence of oral nicotine product use continues to increase, additional disparities may emerge. Importantly, demographic characteristics should not be interpreted as risk factors for nicotine/tobacco use. This study examined differences in prevalence of susceptibility to oral nicotine product use in order to identify groups that may be at high risk. Future research is needed to identify reasons underlying differences in susceptibility between sociodemographic groups, including psychosocial factors associated with increased risk of cigarette and e-cigarette use in the general adolescent population (e.g., tobacco advertising, other substance use, peer and household tobacco use)^38,39 and in minoritized populations (e.g., prejudice, discrimination).^40,41 These factors and others may impact susceptibility to oral nicotine product use.

Limitations

This study had limitations. Youth were recruited from high schools in Southern California, which may not be nationally representative of U.S. youth. Therefore, generalizability of results may be limited. Notably, participants in this study were diverse in race and ethnicity, socioeconomic status, and sexual and gender identity. West Coast cities have been test markets for oral nicotine products,¹⁷ indicating that results could be an indicator of future national trends. However, replication in a national sample would enhance generalizability. Odds of susceptibility are not reported for racial/ethnic groups that were underrepresented in our sample. Replication in a sample with greater proportions of Black, American Indian, Alaska Native, Native Hawaiian, and Pacific Islander youth is needed to better understand differences in susceptibility to oral nicotine products by race/ethnicity. Susceptibility to flavored nicotine gum, lozenges, tablets, and/or gummies was assessed in a single question to reduce participant burden. Future work should include survey items with wording that is more refined for fine-grained differentiation between the various types of oral nicotine products (e.g., gums vs. gummies vs. lozenges), as some products may be more appealing to youth than others. Future work could also consider all three facets of sexual orientation (identity, attraction, and behavior) in defining sexual minority adolescents, as the three facets are fluid and not always concordant.⁴² There may be misclassification of sociodemographic characteristics or susceptibility measures due to the subjective nature of self-report data.

CONCLUSIONS

Among youth in Southern California who had never used tobacco, 15.6% of participants reported susceptibility to novel oral nicotine products, including nicotine pouches, gum, lozenges, tablets, and/or gummies. Results suggest that oral nicotine products may be of interest to youth who may not otherwise use other nicotine or tobacco products, including youth from populations historically targeted by tobacco industry marketing and subject to tobacco-related health disparities. If sales of oral nicotine products persist or increase in the United States, surveillance of youth susceptibility to oral nicotine products may be critical for understanding and preventing youth use and poly-use of nicotine products, especially among populations impacted by tobacco-related health disparities.

Highlights.

• Novel oral nicotine products may appeal to adolescents.

• Susceptibility to oral nicotine products was equal to that of cigarettes.

• Lower-income youth had greater odds of oral nicotine product susceptibility.

• Sexual minority youth had greater odds of oral nicotine product susceptibility.

• Oral nicotine products may entice adolescents who would not otherwise use nicotine.