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"Tobacco-free" Nicotine Pouches: Risk Perceptions, Awareness, Susceptibility, and Use among Young Adults in the United States.

BACKGROUND
Nicotine pouches containing synthetic nicotine or tobacco-derived nicotine (TDN) are available in the United States. Synthetic nicotine pouches often are marketed as "tobacco-free nicotine" (TFN), which may alter risk perceptions and/or product appeal. This study examined young adults' perceptions about TFN versus TDN pouches and associations between product perceptions and TFN pouch awareness, susceptibility, and use, respectively.


METHODS
630 young adults (18-25 years) completed an online Qualtrics panels survey in 2021. Participants were informed that TFN pouches contain synthetic nicotine as opposed to TDN. Participants reported on comparative risk perceptions for TFN vs TDN pouches and on TFN pouch awareness, susceptibility, and use. Unadjusted between-groups comparisons and adjusted binary logistic regressions were run to examine relationships between product perceptions and TFN pouch awareness, susceptibility, and use.


RESULTS
Participants were aware of (37.3%), susceptible to (29.2%), or had used TFN pouches (3.8%). In unadjusted comparisons, TFN pouch awareness, susceptibility, and use were associated with disproportionately perceiving TFN pouches as less harmful/better than TDN pouches. In adjusted models, relationships between favorable perceptions and both TFN pouch awareness and susceptibility remained significant.


CONCLUSIONS
The descriptor "tobacco-free" may impact risk perceptions and appeal of nicotine pouches among young adults. While no direct relationship was observed between TFN perceptions and TFN pouch use in the adjusted model, perceptions remained related to product awareness and susceptibility which may be linked to future use. Continued surveillance is needed to fully determine how the term "tobacco-free" on product packaging and advertising impacts longitudinal public health outcomes.


IMPLICATIONS
Nicotine pouches originally contained tobacco-derived nicotine. Today, numerous brands of synthetic nicotine pouches, which often are marketed as "tobacco-free," are available on the market. We informed participants that "tobacco-free nicotine" pouches contain synthetic nicotine and examined comparative risk perceptions (i.e., tobacco-free vs tobacco-derived nicotine pouches) and TFN pouch awareness, susceptibility, and use. Perceiving tobacco-free nicotine pouches as less harmful/better than tobacco-derived pouches was associated with product awareness, susceptibility, and use in unadjusted models and with awareness and susceptibility in adjusted models. Restricting the term "tobacco-free" may become needed if the term inaccurately reduces product risk perceptions and/or increases product appeal.