18C.3 Awareness, perceptions and use of oral nicotine products

18C.3.1 Awareness of products

The majority of research to date examining awareness and use of oral nicotine products has been conducted outside of Australia, and has focused on nicotine pouches. Despite fairly low prevalence of use of oral nicotine pouches (see Section 18C.3.3, below), awareness of the products is relatively common and appears to be growing, particularly among adolescents and young adults. In 2019, 15.9% of a sample of smokers and/or vapers in the UK had heard about nicotine pouches.¹ In Great Britain, 34% of adults had heard of nicotine pouches in 2020, which grew to 44% in 2022.² A survey of Dutch adolescents and adults in 2020 found that 7% were aware of nicotine pouches, and awareness was higher among those under 45.³ Several subsequent studies in the US found that about one-third of young adults had heard of nicotine pouches.^{4, 5} Almost half (46.6%) of respondents to a 2021 US survey of adult tobacco users had heard of or seen nicotine pouches, with awareness significantly higher among younger compared with older people.⁶

18C.3.2 Perceptions of products and reasons for use

Nicotine pouches tend to be perceived as less harmful and less addictive than cigarettes, e-cigarettes, and smokeless tobacco products.⁴ Compared to non-tobacco users, users of tobacco products also perceive oral nicotine products to be less harmful and addictive.⁷ Favourable beliefs about the lesser harmfulness and addictiveness of nicotine pouches predict susceptibility to and current use of the products.⁶ Other common reasons for use include curiosity, the pleasant taste/flavours, discretion and ease of use, social acceptability, and to quit smoking or to reduce the smell of tobacco.^{3, 4}

Research in California found that among Year 9 and 10 students who had never used a nicotine/tobacco product, one in eight was susceptible to oral nicotine products, with susceptibility higher among low socioeconomic status and sexual minority students.⁸ Young people report greater willingness to use new oral nicotine products compared with traditional smokeless tobacco, which may be due to their sleek, discreet design that resembles gum or lollies, as well as adolescents’ knowledge of the harms of tobacco.⁹

18C.3.3 Prevalence of oral nicotine use

18C.3.3.1 Prevalence of use in Australia

There is very little data available on the use of oral nicotine products in Australia. Results from the 2020 International Tobacco Control (ITC) survey showed that 0.1% of Australian smokers and ex-smokers used nicotine pouches, which was significantly lower than Canada, the US, and England.¹⁰

18C.3.3.2 Prevalence of use internationally

In 2023 in the US, 3.1% of high school students reported having ever used nicotine pouches, and 1.7% reported current use (i.e., use in the past month). More than four in five (92.7%) current users reported using a flavoured product, most commonly mint, followed by menthol and fruit flavours.¹¹ In a national US survey of young people (aged 15–24) in 2021–22, 16% had ever used nicotine pouches and 12% currently used the product. About three-quarters (73%) of those currently using oral nicotine were also current smokers.¹² Data from the International Tobacco Control (ITC) project showed a significant increase in nicotine pouch use over time among young people aged 16–19 in the US, from 3.5% in August 2019 to 4.1% in August 2021. Use was more common among those who also used other tobacco/nicotine products.¹³

A number of cross-sectional online surveys in the US have also measured prevalence of nicotine pouch use. A 2021 survey of young adults found that 3.8% reported ever having used nicotine pouches.⁵ Another 2021 survey of 13–40-year-olds found much higher use, with 33% reporting ever use or oral nicotine products (including pouches, lozenges, tablets, gums, and toothpicks), 19% reporting past month use, and 16% reporting past week use.¹⁴ In 2022, one study found that 9.8% of young adults surveyed had ever used nicotine pouches, and 2.2% had used them in the past month.⁴ Among respondents to a 2021 survey of adult tobacco users, 16.4% had ever used and 3.0% currently used nicotine pouches.⁶ Among a sample of e-cigarette users aged 14–20, almost 44% reported ever use of an oral nicotine product, with pouches being the most commonly ever used (29%) and used in the past month (11%).¹⁵ A 2021 survey of adults who smoke found 6% had used pouches.¹⁶

A representative survey of adults in Great Britain found that while use of nicotine pouches was rare at 0.26%, it had doubled from November 2020 to October 2021. Use was more common among current and ex-smokers, and among users of e-cigarettes and NRT.¹⁷ A more recent survey found that in 2022, 3.9% of adults in Great Britain had tried nicotine pouches. Among people who were current smokers, 12.4% had tried them, while 14.4% of people who vaped had tried them.² Results from the 2020 ITC Four Country Smoking and Vaping Survey found that among current and recent ex-smokers, the prevalence of nicotine pouch use was 1.1% in England, 0.9% in Canada, and 0.7% in the US.¹⁰ A Dutch survey of adolescents and adults in 2020 found that 0.56% had ever used nicotine pouches, with the highest ever use among 25–44-year-olds. One in ten ever users used the products daily, and among current users, about one in three reported using at least 16 pouches per day.³  

References

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2. Action on Smoking and Health. Awareness and use of nicotine pouches.  2022. Available from: https://ash.org.uk/resources/view/awareness-and-use-of-nicotine-pouches

3. Havermans A, Pennings JLA, Hegger I, Elling JM, de Vries H, et al. Awareness, use and perceptions of cigarillos, heated tobacco products and nicotine pouches: A survey among Dutch adolescents and adults. Drug and Alcohol Dependence, 2021; 229(Pt B):109136. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34763136

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5. Morean ME, Bold KW, Davis DR, Kong G, Krishnan-Sarin S, et al. Awareness, susceptibility, and use of oral nicotine pouches and comparative risk perceptions with smokeless tobacco among young adults in the United States. PLoS One, 2023; 18(1):e0281235. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36716297

6. Sparrock LS, Phan L, Chen-Sankey J, Hacker K, Ajith A, et al. Nicotine Pouch: Awareness, Beliefs, Use, and Susceptibility among Current Tobacco Users in the United States, 2021. International Journal of Environmental Research and Public Health, 2023; 20(3). Available from: https://www.ncbi.nlm.nih.gov/pubmed/36767414

7. Mays D, Long L, Alalwan MA, Wagener TL, Shang C, et al. The Effects of Oral Nicotine Pouch Packaging Features on Adult Tobacco Users' and Non-Users' Product Perceptions. International Journal of Environmental Research and Public Health, 2023; 20(4). Available from: https://www.ncbi.nlm.nih.gov/pubmed/36834078

8. Vogel EA, Barrington-Trimis JL, Harlow AF, Wong M, Cho J, et al. Prevalence of and disparities in adolescents' susceptibility to novel oral nicotine products marketed as "tobacco-free". Preventive Medicine, 2023; 166:107387. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36503016

9. Tackett AP, Wong M, Cho J, Harlow AF, Vogel EA, et al. Willingness to Use Commercial Nicotine Gums, Lozenges, and Gummies Among Nontobacco Using Adolescents in Southern California. The Journal of Adolescent Health, 2023; 72(2):277-86. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36470691

10. Li L, Borland R, Cummings KM, Gravely S, Quah ACK, et al. Patterns of Non-Cigarette Tobacco and Nicotine Use Among Current Cigarette Smokers and Recent Quitters: Findings From the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine & Tobacco Research, 2021; 23(9):1611-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33693833

11. Birdsey J, Cornelius M, Jamal A, Park-Lee E, Cooper MR, et al. Tobacco Product Use Among U.S. Middle and High School Students - National Youth Tobacco Survey, 2023. Morbidity and Mortality Weekly Report, 2023; 72(44):1173-82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37917558

12. Patel M, Kierstead EC, Kreslake J, and Schillo BA. Patterns of oral nicotine pouch use among U.S. adolescents and young adults. Preventive Medicine Reports, 2023; 34:102239. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37228836

13. Schneller LM, Felicione NJ, Hammond D, Goniewicz ML, and O'Connor RJ. Tobacco-Free Oral Nicotine Product Use Among Youth in the U.S., 2019-2021. AJPM Focus, 2023; 2(1):100061. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37789938

14. Gaiha SM, Lin C, Lempert LK, and Halpern-Felsher B. Use, marketing, and appeal of oral nicotine products among adolescents, young adults, and adults. Addictive Behaviors, 2023; 140:107632. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36731224

15. Couch ET, Halpern-Felsher B, Werts M, and Chaffee BW. Use of Emerging and Conventional Oral Tobacco Among Adolescent and Young Adult E-Cigarette Users. Substance Use and Misuse, 2023; 58(2):283-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36645845

16. Hrywna M, Gonsalves NJ, Delnevo CD, and Wackowski OA. Nicotine pouch product awareness, interest and ever use among US adults who smoke, 2021. Tobacco Control, 2023; 32(6):782-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35217596

17. Tattan-Birch H, Jackson SE, Dockrell M, and Brown J. Tobacco-free Nicotine Pouch Use in Great Britain: A Representative Population Survey 2020-2021. Nicotine & Tobacco Research, 2022; 24(9):1509-12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35417551