United States: Co-use of nicotine pouches and e-cigarettes among high school students raises concerns

A study[1] A large-scale US study, published in JAMA Network Open in May 2025, highlights a significant increase in the use of nicotine pouches among adolescents, alongside notable co-use with e-cigarettes. This change in practices raises new public health concerns, in a context of diversification of nicotine products according to the authors.

The study, conducted by a team of researchers from the University of California, San Diego, is based on a cross-sectional survey conducted in schools in the United States. Data were collected between October 2023 and February 2024 from 10,400 students in grades 10 and 12 (equivalent to the second and final year of high school in France) from 32 schools across seven states.

The questionnaires measured the use of nicotine pouches, e-cigarettes, and co-use over periods ranging from 30 days to 12 months prior to the survey. Analyses were adjusted for several sociodemographic variables, including gender, ethnic group, educational level, and geographic area type (urban, rural, or mixed).

Worrying figures on the rise of nicotine sachets

The results reveal a marked increase in the use of nicotine pouches among adolescents, both alone and in co-use with e-cigarettes.

In 2023, 3.% of students reported using nicotine pouches in the 30 days preceding the survey. This figure increased to 5.4TP3T in 2024, representing a relative increase of 80TP3T. Furthermore, 4.7TP3T of students reported using nicotine pouches in the 12 months preceding the 2023 survey; this proportion increased to 7.% one year later.

Regarding e-cigarettes, the prevalence of use in the 30 days preceding the survey decreased slightly, from 20% in 2023 to 17.6 % in 2024. However, the decline remains limited and does not offset the growth of new products.

The study also highlights an increase in co-use. In 2023, 2.1% of students reported using both nicotine pouches and e-cigarettes in the previous 12 months. This proportion increased to 3.6% in 2024, a relative increase of 71%. This co-use primarily concerns students who reported frequent use of one or the other product.

Demographically, nicotine pouch use is higher among boys (8.2 µg/mL vs. 2.3 µg/mL among girls for reported use in the 12 months preceding the survey in 2024). Prevalence is also higher among non-Hispanic white students (9.7 µg/mL), as well as among adolescents living in rural areas (7.3 µg/mL vs. 4.2 µg/mL in urban areas). Nicotine pouch use also appears to be more common among students in their 12th grade, suggesting increasing exposure with age.

A diversification of products that complicates prevention

The data collected in this study highlight the rapid emergence of nicotine pouches in adolescent consumption practices in the United States, in a context of changing nicotine market products. These products, often flavored and packaged in attractive but discreet packaging, benefit from an image perceived as less harmful or more "acceptable" than e-cigarettes or traditional tobacco cigarettes. Their smoke- and vapor-free consumption method makes them easier to conceal in schools.

The rise in the use of nicotine pouches, combined with their co-use with e-cigarettes, has led researchers to warn of a phenomenon of complementarity, not substitution. In other words, the use of these new products does not replace that of e-cigarettes, but rather adds to them in young people's consumption patterns. This raises crucial questions about the role of these products in nicotine initiation, the risks of increased addiction, and the difficulty of implementing effective prevention strategies in a constantly diversifying market.

Finally, the authors emphasize the need for stricter regulation of these products, particularly with regard to access by minors, flavorings, labeling, and advertising. They recommend implementing enhanced epidemiological monitoring. In Europe, where these products are still relatively unseen but are beginning to spread, as in France, these data constitute an important warning signal.

©Generation Without Tobacco

AE

[1] Han D, Harlow AF, Miech RA, et al. Nicotine Pouch and E-Cigarette Use and Co-Use Among US Youths in 2023 and 2024. JAMA Netw Open. 2025;8(4):e256739. doi:10.1001/jamanetworkopen.2025.6739