Shifting nicotine product preferences observed in US high school students

University of Southern California and University of Michigan researchers report expanded use of non-tobacco nicotine products among U.S. adolescents. While exclusive e-cigarette use has declined, dual use of nicotine pouches and e-cigarettes has risen.

Nicotine use among U.S. adolescents declined during a period of intensified tobacco-related prevention efforts between 1997 and 2013. E-cigarettes reintroduced nicotine to youth by creating a non-tobacco product sector marketed as distinct from combustible tobacco. Marketing strategies framed these products as socially acceptable and less harmful.

Nicotine pouches recently entered this sector and share similar characteristics with e-cigarettes. Flavored pouches are sold in fruit, candy, and mint varieties, and are being promoted on social media platforms. Pouches do not contain tobacco leaves, require no spitting, and are perceived as discreet. Adolescents may view them as more socially acceptable and less harmful than cigarettes, chewing tobacco, or vaping.

Traditional smoking prevalence has long been studied in youth, along with the recent addition of e-cigarettes, yet comprehensive analyses to quantify prevalence, trends, and patterns in youth use of nicotine pouches have been slow to catch up with the emerging trend. Surveillance gaps have raised concerns about the completeness of current data used to inform public health decisions, including recent FDA authorization of flavored pouch products.

In the study titled "Nicotine Pouch and E-Cigarette Use and Co-Use Among US Youths in 2023 and 2024," published in JAMA Network Open, researchers conducted a cross-sectional study to estimate the prevalence and sociodemographic correlates of pouch and e-cigarette use among adolescents.

Use data were taken from Monitoring the Future, a national survey that conducts annual in-classroom, self-administered assessments among representative samples of U.S. 10th- and 12th-grade students. Survey data included 10,146 participants, with 5,674 in 10th grade and 4,472 in 12th grade, surveyed during 2023 and 2024.

Nicotine pouch use was assessed in a randomly selected one-third of students in each grade and year. Participants self-reported their lifetime, past-12-month, and past-30-day use of nicotine pouches and e-cigarettes. For each timeframe, researchers constructed a four-level co-use variable: no use, exclusive pouch use, exclusive e-cigarette use, and dual use.

Survey items also included sex, race and ethnicity, population density of school location, and four-year college plans. Responses were used to stratify analyses and estimate associations between sociodemographic variables and product use.

Nicotine pouch use increased between 2023 and 2024 across all time frames. Lifetime use rose from 3.0% to 5.4%, past-12-month use from 2.4% to 4.6%, and past-30-day use from 1.3% to 2.6%. Exclusive e-cigarette use declined across all measures. Lifetime use decreased from 25.7% to 22.0%, past-12-month use from 17.9% to 14.0%, and past-30-day use from 12.3% to 10.1%. Each decline was statistically significant.

Dual use of nicotine pouches and e-cigarettes increased. Lifetime co-use rose from 2.7% to 4.7%, past-12-month co-use from 2.1% to 3.6%, and past-30-day co-use from 1.1% to 1.7%, though the past-30-day change was not statistically significant.

Any use of non-tobacco nicotine products (using either or both products) did not significantly change across years. Lifetime prevalence decreased from 28.8% to 27.4%, past-12-month use from 20.3% to 18.6%, and past-30-day use from 13.6% to 12.7%.

Use patterns varied by sex, grade, race and ethnicity, geographic region, and college plans. Nicotine pouch use was more common among male students, while e-cigarette use was more common among female students. Use of both products was higher among 12th-grade students compared with 10th-graders. Non-Hispanic white and rural students reported higher rates of use, especially of nicotine pouches; they were four times as likely to use them as their urban peers. Students without four-year college plans had higher rates of use with both products.

Among Hispanic students, past-12-month pouch use increased from 0.4% in 2023 to 2.8% in 2024, a change greater than the corresponding increase among non-Hispanic white students. No other significant subgroup interaction effects were observed across years.

Increased use of nicotine pouches and dual use with e-cigarettes coincided with a decline in exclusive e-cigarette use. The trends reflect a shift in nicotine delivery products rather than a change in the overall prevalence of non-tobacco nicotine use among 10th- and 12th-grade students.

Researchers noted that rising pouch use may reflect increased marketing of flavored pouch products and their appeal to adolescents due to perceptions of discreetness, flavor variety, and distinction from tobacco-leaf products. The study authors called for expanded surveillance, regulation, and prevention strategies to address youth use of nicotine pouches and co-use with e-cigarettes.

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