Background Tobacco-free nicotine pouches are one of the fastest growing tobacco product categories in the US market. However, data on awareness, appeal or ever use of these products in the USA are limited. Methods We surveyed a population-based sample of US adults who smoked (n=1018) between January and February 2021 about awareness, ever use of or interest in nicotine pouches. Multivariable logistic regression models explored the relationship between nicotine pouch variables and demographic and tobacco use characteristics. Results In early 2021, 29.2% of adults who smoked had ever seen or heard of nicotine pouches, 5.6% had ever tried pouches and 16.8% reported interest in using pouches in the next 6 months. Adults who smoked aged 18–44 years and those who had ever used smokeless tobacco (SLT) were more likely to be aware of nicotine pouches. Interest in using nicotine pouches was more prevalent among adult smokers who planned to quit within 6 months, attempted to quit before using counselling or another tobacco product and had ever used pouches. Among adults who smoked, those with more education had lower odds of ever using nicotine pouches while those who had attempted to quit before using traditional methods or ever used SLT had higher odds of ever use. Conclusion Levels of awareness, appeal and trial of nicotine pouches among US adults who smoke were modest, with variation by age, education, quit plans and quit attempt methods. Continued surveillance is warranted, including among naïve users and users of other tobacco and nicotine products.

Physicians are rated the most trustworthy source of information for smokers and thus play an increasing role in disseminating information on e-cigarettes to patients. Therefore, it is important to understand what is currently being communicated about e-cigarettes between physicians and patients. This study explored the knowledge, beliefs, communication, and recommendation of e-cigarettes among physicians of various specialties. Semi-structured interviews were conducted in early 2016 with 35 physicians across five different specialties. Interviews were transcribed and coded for the following deductive themes: (1) tobacco cessation recommendation practices, (2) knowledge of e-cigarettes, (3) communication of e-cigarettes with patients, (4) recommendation of e-cigarettes, and (5) general beliefs about e-cigarettes. Physicians across all specialties reported having conversations with patients about e-cigarettes. Conversations were generally prompted by the patient inquiring about e-cigarettes as a cessation method. Overall, physicians felt there was a lack of information on the efficacy and long term health effects but despite lack of evidence, generally did not discourage patients from trying e-cigarettes as a cessation device. Although physicians did not currently recommend e-cigarettes over traditional cessation methods, they were open to recommending e-cigarettes in the future if adequate data became available suggesting effectiveness. Patients are inquiring about e-cigarettes with physicians across various specialties. Future research should continue to study physicians' perceptions/practices given their potential to impact patient behavior and the possibility that such perceptions may change over time in response to the evidence-base on e-cigarettes.

Background: Nicotine pouches and lozenges are increasingly available in the United States, and sales are growing. The brands of nicotine pouch products with the largest market share are produced by tobacco companies. Objective: The aim of this study is to examine the marketing of 5 oral nicotine products sold by tobacco companies. Methods: Internet, radio, television, print, and web-based display advertisements between January 2019 and March 2020 for 6 brands of nicotine pouches and lozenges were identified through commercially available marketing surveillance systems supplemented by a manual search of trade press and a review of brand websites. A total of 711 advertisements (122 unique) were analyzed to identify characteristics, themes, marketing strategies, and target audiences, and qualitatively compared by brand. All 5 brand websites were also analyzed. Coders examined the entirety of each advertisement or website for products, marketing claims, and features and recorded the presence or absence of 27 marketing claims and lifestyle elements. Results: All 6 brands of nicotine pouch products spent a total of US $11.2 million on advertising in 2019, with the most (US $10.7 million) spent by the brand Velo, and 86.1% (n=105) of the unique advertisements were web-based. Of the 711 total nicotine pouch advertisements run in 2019, the 2 brands Velo (n=407, 57%) and ZYN (n=303, 42%) dominated. These brands also made the greatest number of advertising claims in general. These claims focused on novelty, modernity, and use in a variety of contexts, including urban contexts, workplaces, transportation, and leisure activities. Of the 122 unique advertisements, ZYN’s most common claims were to be “tobacco-free,” featuring many flavors or varieties, and modern. Velo was the only brand to include urban contexts (n=14, 38.9% of advertisements) or freedom (n=8, 22.2%); Velo advertisements portrayed use in the workplace (n=15, 41.7%), bars or clubs (n=5, 13.9%), leisure activities (n=4, 11.1%), transportation (n=4, 11.1%), sports (n=3, 8.3%), cooking (n=2, 5.6%), and with alcohol (n=1, 2.8%). Velo and ZYN also included most of the images of people, including women and people of color. The 36 Velo ads included people in advertising in 77.8% (n=28) of advertisements, and of those advertisements with identifiable people, 40% (n=4) were young adults and 50% (n=5) were middle-aged. About one-third (n=11, 35.5%) of the 31 unique ZYN advertisements included people, and most identifiable models appeared to be young adults. Brands such as Rogue, Revel, Dryft, and on! focused mainly on product features. All nicotine pouch products made either tobacco-free, smoke-free, spit-free, or vape-free claims. The most common claim overall was “tobacco-free,” found in advertisements from Rogue (1/1, 100%), ZYN (30/31, 96.8%), Velo (19/36, 52.8%), and Dryft (1/3, 33.3%), but not Revel. Conclusions: Nicotine pouches and lozenges may expand the nicotine market as tobacco-free claims alleviate concerns about health harms and advertising features a greater diversity of people and contexts than typical smokeless tobacco advertising. The market leaders and highest-spending brands, ZYN and Velo, included more lifestyle claims. Surveillance of nicotine pouch marketing and uptake, including influence on tobacco use behaviors, is necessary.

Electronic cigarettes (e-cigarettes) have been the most commonly used tobacco product among adolescents since 2014.¹ The 2018 National Youth Tobacco Survey revealed that e-cigarette use increased considerably among high school students between 2017 and 2018.¹ Among high school students, current e-cigarette use increased from 11.7% in 2017 to 20.8% in 2018,² and frequent use (≥20 of past 30 days) more than doubled from 2017 (2.5%) to 2018 (5.9%).¹ Although the JUUL brand was recognized as likely contributing to the rapid growth in e-cigarette use, the 2018 National Youth Tobacco Survey did not ask about use of JUUL specifically.²

Background ZYN is the leading nicotine pouch brand and a predominant driver of nicotine pouch advertising. In November 2022, Philip Morris International (PMI) acquired Swedish Match, the manufacturer of ZYN. Methods We conducted a content analysis of 207 US-based consumer-facing ZYN advertisements (ads) from January 2019 to June 2023 to delineate the characteristics of ZYN ads and compare them before and after Swedish Match was acquired by PMI. Results Most ZYN ads were on digital media, and nearly all included information on nicotine strength and flavour. Peppermint was the most advertised flavour across time. After the acquisition, ZYN ads included significantly fewer ‘tobacco-free’ claims, whereas ‘spit-free’ claims significantly increased. The most common marketing claims were that multiple choices of products were available, followed by easy to buy, change, sales success, ability to use anywhere and improved social interaction before and after the acquisition. The percentages of ads with easy to buy, change and sales success claims, reward programmes and those linked to websites significantly increased after the acquisition. Conclusions After PMI acquired Swedish Match, ZYN ads used ‘tobacco-free’ claims less frequently. The most advertised marketing claims remained unchanged but were made more frequently in post-acquisition ads. Such claims, together with the promotion of reward programmes and links to websites for easy purchase, may attract young people or those who do not use tobacco to ZYN, indicating a need for increased monitoring and potential restrictions.

Objectives: To examine sex differences in the relationship between serious psychological distress (SPD) and tobacco use. Methods: The 2010 National Health Interview Survey data (N = 26,907) were examined to assess tobacco use among adults with and without SPD. Prevalence and odds ratios (OR) were calculated. The possible moderating effect of sex was examined. Results: Lifetime and current use of cigarettes, cigars and smokeless tobacco (SLT) was more prevalent among those with SPD. Sex interaction terms were significant when modeling lifetime and current cigar and SLT use. The adjusted OR for all tobacco outcomes was greater for women than for men. Conclusions: Findings suggest a stronger association of SPD and tobacco use for women.