Oral nicotine pouch use among United States middle and high school students, 2021 to 2025
Haoxiong Sun, Harry Tattan‐Birch, Melissa Oldham, Sharon Cox, Sarah E. JacksonAbstract
Aims
To examine oral nicotine pouch use among United States (U.S.) middle and high school students by (1) estimating prevalence in 2025 across demographic and other tobacco/nicotine product use subgroups, (2) assessing trends from 2021 to 2025, and (3) identifying factors independently associated with current pouch use.
Design
Annual cross‐sectional survey.
Setting
United States.
Participants
124 264 middle and high school students (typically aged 11–18 years) in the National Youth Tobacco Survey 2021–2025 (n = 20 413, 28 291, 22 069, 29 861 and 23 630). 117 864 students with classifiable pouch use were included in the trend analyses and 22 854 in the 2025 analyses.
Measurements
We estimated annual survey‐weighted prevalence of ever, current (≥1 day in the past 30 days) and current frequent (≥20 days) pouch use, overall and by sex, school level, race/ethnicity, and by current use of cigarettes, e‐cigarettes, other non‐pouch products and any non‐pouch product, each analysed separately. Trends were assessed with survey‐weighted Poisson regression using orthogonal linear and quadratic year contrasts, the quadratic testing departure from a constant multiplicative trend. Using 2025 data we estimated adjusted prevalence ratios (APRs) for current pouch use.
Results
In 2025, 3.8% [95% confidence interval (CI): 3.1–4.6] of students reported ever using pouches, 1.7% (1.4–2.1) current use, and 0.4% (0.3–0.6) frequent use. Current use rose from 0.8% (0.6–1.0) in 2021 to 1.6% (1.1–2.2) in 2023 then changed little at 1.8% (1.5–2.1) in 2024 and 1.7% in 2025. The quadratic year term was 0.75 (0.57–0.99), consistent with deceleration but imprecise. Ever use rose across all five waves from 2.1% (1.7–2.5) with no departure from linearity (quadratic 1.00, 0.81–1.22). Increases were consistent across subgroup levels with reliable estimates in all years. In 2025, current pouch use was higher among males (2.4% vs. 1.0%) and among current users of any other product (20.6% vs. 0.4%). Most current pouch users (77.4%) also currently used another product, though 11.1% reported no lifetime use. In fully adjusted models, associations were strongest for other non‐pouch product use (APR = 13.78, 95% CI: 8.39–22.65), then e‐cigarette (4.32, 2.75–6.80) and cigarette use (1.49, 1.08–2.07).
Summary
Oral nicotine pouch use among United States middle and high school students remains uncommon. Current use rose between 2021 (0.8%) and 2023 (1.6%) and has since levelled off, while ever use continued to increase. Use is largely concentrated among users of other tobacco or nicotine products, but a minority report no current or lifetime use of other products.