A new study found that the prevalence of nicotine pouch use was low in U.S. adults despite a 641% increase in sales of the products between 2019 and 2022. Researchers say the findings raise questions about who is using the millions of nicotine pouches sold in the U.S. and why.
Nicotine pouches, a new commercial tobacco product, contain a crystalline powder with nicotine, flavorings (including fruit, mint or candy) and other additives. They do not cause respiratory harm and are perceived by some as an alternative to help adults who smoke tobacco quit. Nicotine pouches have recently gained attention over concerns that their flavors and trendy social media marketing campaigns are attracting youth users. However, limited data on usage among adults has been collected since the new products entered the market.
Now, a study from the Keck School of Medicine of USC and the University of Nebraska Medical Center analyzed nicotine pouch use in a nationally representative sample of 39,557 U.S. adults. The study found that 2.9% of adults had ever used nicotine pouches, with 0.4% reporting current use. The majority of adults currently using pouches also currently smoke cigarettes. Additionally, 5.2% of those who attempted to quit smoking in the past year and had relapsed back to smoking reported using pouches to help with their cessation efforts. The study, funded by the National Institutes of Health (NIH), was just published in JAMA.
"The low prevalence of nicotine pouch use in adults surprised us, given the rapid increase in sales," said study coauthor Adam Matthew Leventhal, PhD, a professor in the department of population and public health sciences at the Keck School of Medicine and executive director of the USC Institute for Addiction Science. "But it's also possible that the sales are being diverted to adolescents, who were not represented in this survey."
Patterns of pouch use
Data for the study were collected through the Current Population Survey (CPS) Tobacco Use Supplement in September 2022.
The CPS is a monthly survey of U.S. adults that uses rigorous research methods to ensure its participants represent an accurate cross-section of the country's population, making the results reliable enough to influence important policy decisions. The Tobacco Use Supplement includes straightforward questions about cigarette smoking, attempts to quit smoking and—for the first time in September 2022—the use of nicotine pouches.
Of 39,558 survey respondents, 2.9% had ever used nicotine pouches, and 0.4% were currently using them. Adults who currently smoked (10.8%) or formerly smoked (6.7%) were more likely to report ever using nicotine pouches compared to people who had never smoked (1.1%). Current use of nicotine pouches was also higher among adults who currently smoked (1%) and formerly smoked (0.7%) compared to those who had never smoked (0.2%). Pouch use, both past and present, was lower in adults under 65, but higher in males and non-Hispanic whites.
Among those who currently smoked who tried to quit in the past year, more reported trying to switch to e-cigarettes (21.6%) than nicotine pouches (5.2%) to help them quit.
One question raised by the findings is whether adults who use nicotine pouches may be using them to "top off" nicotine in situations where they cannot smoke or use other tobacco products, Leventhal said, rather than as a way to quit smoking. Instead of reducing the health risks of cigarette smoking, that use pattern could actually make nicotine dependence more severe.
Based on the study results, Leventhal estimates that of all U.S. adults who currently used nicotine pouches in 2022, about 35% had previously smoked cigarettes and 25% were currently smoking cigarettes. The remaining 40% of adult pouch consumers had never regularly smoked cigarettes and could be at risk for developing nicotine dependence.
"In summary, we didn't see a large population of adults using nicotine pouches, and fewer appear to be using them in a fashion that would potentially reduce their harm from smoking cigarettes," Leventhal said.
Regulating nicotine pouches
New nicotine products typically go straight to market before the U.S. Food and Drug Administration (FDA) reviews marketing applications and decides whether to authorize or ban each product.
That decision involves weighing potential public health benefits, such as whether a product provides a safer alternative for adults who smoke, against risks, such as whether it may increase nicotine dependence among youth. Applications from major manufacturers of nicotine pouches are currently under review by the FDA.
"Regulators can take our data and put it into that equation," Leventhal said. "What our study suggests is that there's not a large population of adults who smoke who are using these products to quit."
This study is part of the USC Tobacco Center of Regulatory Science, one of seven national centers supported by the NIH and FDA to collect evidence that can inform tobacco product regulation. In collaboration with the University of Michigan and other institutions, USC researchers are also conducting a parallel study to investigate adolescent use of nicotine pouches. They are looking at how pouch use relates to shifting teen usage patterns of other nicotine products, including e-cigarettes.
About this research
In addition to Leventhal, the study's other author is Hongying Daisy Dai from the College of Public Health, University of Nebraska Medical Center, Omaha.
This work was supported by the National Cancer Institute [U54CA180905] and the National Institute on Drug Abuse [R21DA058328].
