Compared perceptions of oral nicotine pouches and smokeless tobacco among young adults

In a recent study published in the journal PLoS One, researchers surveyed young individuals in the United States about their awareness/use of and susceptibility to nicotine pouches (NPs). 

Study: Awareness, susceptibility, and use of oral nicotine pouches and comparative risk perceptions with smokeless tobacco among young adults in the United States. Image Credit: monte_a /

What are NPs?

Oral NPs contain nicotine without tobacco leaves in a similar quantity as smokeless tobacco products. The toxicant profile of NPs is similar to that of nicotine replacement therapy, according to a previous study.

NPs may be attractive to those using smokeless tobacco. However, NPs can be harmful if they get popular among vulnerable populations, including adolescents and young adults.

About the study

In the present study, researchers examine the awareness/use of and susceptibility to NPs among young adults in the U.S. Individuals between the ages of 18 and 25 completed an anonymous 20-minute online survey between September 2021 and October 2021. The researchers then randomized 50% of participants from the parent study, which assessed risk perceptions about tobacco-free e-cigarettes, to constitute the analytic sample for the current analysis.

Participants were provided with a description of NPs and asked to report on comparative product perceptions between NPs and smokeless tobacco. Product perceptions were developed based on the smokeless tobacco expectancies scale and manufacturer claims about NPs. Next, the study participants reported on NP awareness, with those who were aware of NPs indicating whether they ever used them.

The researchers examined susceptibility to NPs by asking participants who had never used or heard of NPs if they would ever use one in the next year. Additionally, participants indicated if they had ever used e-cigarette devices, hookah, cigars, and smokeless tobacco, among other products. Two sets of independent sample t-tests were performed to determine whether susceptible and non-susceptible individuals should be stratified into distinct categories according to prior NP awareness.

A one-way analysis of variance (ANOVA) was performed to compare product perceptions based on NP use and susceptibility. A multinomial logistic regression was performed, including demographics, product perceptions, and previous use of e-cigarettes, cigars, hookah, and smokeless tobacco, as predictors of NP use and susceptibility.

Study findings

Overall, 609 subjects, with a mean age of 21.24, were included in the study. About 56% of the study participants were female, whereas 53.5% were White. The rate of ever-use of NPs was 10.3%, which was lower than that of other tobacco products. In total, 41.5% of subjects were aware of NPs and 23.5% were susceptible to NPs for future use.

There were no significant differences in product perceptions based on prior NP awareness. Therefore, three mutually exclusive categories of individuals were created to reflect those who were susceptible, non-susceptible, and had used NPs. The mean scores for individual product perceptions between NPs and smokeless tobacco stood at the mid-range of the scale.

Young adults susceptible to NPs and those who used NPs had stronger favorable perceptions of NPs relative to smokeless tobacco than non-susceptible individuals. There were no differences in the perceptions between NP-susceptible individuals and those who used NPs.

Susceptible individuals were more likely to be male, have used e-cigarettes, and report greater favorable perceptions of NPs than non-susceptible individuals. Likewise, individuals who used NPs were more likely to have used cigars, smokeless tobacco, and e-cigarettes, as well as report favorable perceptions of NPs, than non-susceptible individuals. Those who used NPs were also younger and more likely to have used smokeless tobacco and cigars than susceptible individuals.


The awareness rate about NPs among young adults was 41.5% in the U.S., which is consistent with a previous estimate. However, the susceptibility rate of 23.5% was considerably higher than previously reported among smokers. Moreover, the rate of NP use of 10.3% was higher in young adults than prior estimates in smokers, high school students, and people between 18-20 years of age at 5.6%, 3%, and 5.2%, respectively.

The study findings suggest uncertainty about the relative risk of NPs and smokeless tobacco, as the median response to comparative product perceptions was neither agree nor disagree. However, significant differences were evident when examined by NP status. There was a strong perception among susceptible individuals and those who used NPs that NPs were less harmful than smokeless tobacco relative to non-susceptible subjects.

Nevertheless, the differences in product perceptions were insignificant between susceptible individuals and those who used NPs. Taken together, the study findings suggest that young adults are aware of NPs and susceptible to and use them. More research is required to identify all factors associated with NP use and susceptibility.

Journal reference:

  • Morean, M. E., Bold, K. W., Davis, D. R., et al. (2023). Awareness, susceptibility, and use of oral nicotine pouches and comparative risk perceptions with smokeless tobacco among young adults in the United States. PLoS ONE. doi:10.1371/journal.pone.0281235