Nicotine pouches (NP, i.e., sachets containing microcrystalline cellulose, nicotine, flavorings, and other additives, which contain no tobacco leaf) are increasingly marketed in the US (Marynak et al., 2021). During 2016–2020, U.S. dollar sales of NPs increased by 305 % (Marynak et al., 2021). NPs might appeal to youth because they can be used discreetly and come in a wide availability of flavors (Marynak et al., 2021, Kramer et al., 2023a). Although NPs lack certain toxins present in combustible tobacco smoke, they still deliver significant amounts of nicotine to the blood stream through buccal absorption, (McEwan et al., 2022) and may possess substantial addiction potential. Given that nicotine exposure during adolescence may interfere with optimal neurocognitive development (Reynolds et al., 2025) and potentially increase risk of depression, (Dierker et al., 2015) understanding factors implicated in adolescent NP use is important.

A recent review found that 35–42 % of adolescents and young adults had heard of NPs through 2023 (Travis et al., 2024) and 2.3 % of US middle and high school students reported NP ever use in 2023 (Birdsey et al., 2023). The increased awareness may be due to marketing influences and the positioning of NPs as a viable and practical alternative for nicotine intake (Lyu et al., 2025, Duan et al., 2024). Awareness and use of NPs may be substantially higher in youth who use other tobacco/nicotine products due to the perception that NPs can be used in places where inhaled products (e.g., e-cigarettes) or traditional smokeless tobacco (e.g., chewing tobacco, snuff, plug, dipping tobacco, snus) are prohibited or difficult to conceal. The only published study based on nationally representative data that examined youth NP awareness used the 2021 National Youth Tobacco Survey, (Kramer et al., 2023b) which showed that NP awareness was more prevalent among adolescents who currently use smokeless tobacco (64.5 %), followed by cigarettes (53.0 %), e-cigarettes (51.6 %), heated tobacco products (50.7 %), and cigars (47.6 %) relative to the general population (35.5 %) (Kramer et al., 2023b). Similarly, ever NP use was prevalent among adolescents who currently use smokeless tobacco (50.5 %), cigarettes (18.4 %), or e-cigarettes (14.8 %) relative to the general population (1.9 %) (Kramer et al., 2023b). Adolescents with tobacco/nicotine and other substance use (TOSU) may be more likely to use NPs due to shared risk factors (e.g., sensation-seeking, peer influence) and common liability (Ramo et al., 2012, Schlienz and Lee, 2018, Vanyukov et al., 2012). Little is known about how TOSU is associated with NP use.

This cross-sectional investigation used data from the 2023 Monitoring the Future (MTF) survey, (Bachman et al., 2015) a nationally representative survey of U.S. adolescents, to examine the association of TOSU with NP awareness and use prevalence. Documenting these associations can inform prevention efforts by identifying which groups of adolescents are at risk for NP use and guiding targeted interventions.