From packs to pouches: the first evidence on the spread of nicotine pouches among 15–19‑year‑olds in Italy| Tabaccologia

Abstract

Background: Nicotine pouches represent a new oral nicotine delivery product, promoted as an alternative to traditional tobacco products, that raise public health concerns, especially due to their potential appeal among adolescents. This study presents the first national prevalence estimates of use among Italian students aged 15–19, based on data from the 2024 ESPAD®Italia study.

Methods: ESPAD®Italia is an annual survey representative of the upper secondary school student population. In 2024, a total of 20,201 students (mean age 17.1 years; 51.8% male) completed an anonymous self-administered questionnaire, which included new items on nicotine pouch use. Descriptive analyses and a multivariable logistic regression were conducted.

Results: 6.8% of students reported having used nicotine pouches at least once in their lifetime, 5.2% had used them in the past year, and 3.0% in the past month, with higher rates among boys. Among users, 2.0% had not used any other nicotine-containing product in the past month, and 0.4% had never tried any other nicotine product in their life. Nicotine pouch use was positively associated with daily smoking, e-cigarette use, cannabis use, binge drinking, and having parents who vape. Being female, older in age, or having parents who smoke traditional cigarettes were inversely associated with use.

Conclusions: Nicotine pouch use is already prevalent among Italian adolescents, including among those with no experience using other nicotine products. Ongoing monitoring and the development of targeted prevention strategies are urgently needed.

Introduction

Nicotine pouches are a new oral smokeless product in the Italian market context, commercialized as an alternative to tobacco-based products. These pouches are made of nonwoven plant-fibre fabric (NWF) and are intended to be placed between the gum and the upper lip, where they release nicotine that is absorbed through the oral mucosa in a slower process than inhalation. Apart from nicotine, usually in the form of salt, these products contain fillers such as microcrystalline cellulose or gum arabic, water, flavourings, sweeteners, and pH stabilizers to facilitate nicotine absorption through cell membranes in a basic environment.

Nicotine pouches were initially developed as an alternative to snus, a type of smokeless tobacco particularly common in Northern European countries, and were first launched in the United States by a Swedish company in 2014. They were later marketed in Sweden and Norway between 2016 and 2018. More recently, this product has expanded into other European markets and, since 2020, it has gained significant popularity in Italy, particularly among those seeking an alternative to smoking or vaping, especially for situations where regulatory restrictions prohibit their use. The pouches may contain varying amounts of nicotine, but beyond the concentration of the active ingredient, several factors influence its absorption, from humidity to pH, from the contact surface with the mucous membranes to the individual characteristics of users.

Although nicotine pouches are considered less dangerous than traditional smoking [1], based on the assumption that most smoking-related diseases are not directly attributable to nicotine but to the toxic chemicals produced by tobacco combustion and inhaled through cigarette smoke [2], it is important to consider that nicotine pouches are often marketed with flavours and aromas that may end up attracting non-smoker as well [3,4]. Their increasing use, particularly among young people, has raised significant public health concerns. However, research on health effects is still in its early stages, and most of the available information comes from studies funded by the tobacco industry [1]. Specifically, the potential public health impact has been partially explored in the United States, where a steady increase in this type of consumption has been observed, including among individuals who do not use other nicotine-based products [5,6].

An import gap is therefore identified in the literature, highlighting the need to deepen the understanding of this phenomenon, particularly in Italy where prevalence data on consumption, especially among adolescents, are lacking.

With the aim of filling this gap, the ESPAD^®Italia 2024 (European School Survey Project on Alcohol and other Drugs) study provides the first quantitative data on the prevalence of nicotine pouch use among Italian students aged 15 to 19. This cross-sectional study, conducted for the first time in 1995 and annually since 1999, collects crucial information on substance use and risky behaviours in a representative sample of secondary school students throughout Italy. In 2024, the survey was enriched with a section on nicotine pouch consumption. The data reveal the first insights into the consumption patterns of this recent product and its relationship with the consumption of other nicotine-based products, such as traditional cigarettes and e-cigarettes. As the first observation point of this emerging trend, these results will be essential for future monitoring efforts and policy development, particularly to protect younger populations.

Methods

Data collection took place through the ESPAD^®Italia 2024 survey, a nationally representative study of Italian high school students (aged 15-19). The survey is conducted annually since 1999 by the Institute of Clinical Physiology of the National Research Council (CNR), aiming to monitor several risk behaviours, including the use of psychoactive substances (e.g., alcohol, tobacco, cannabis, and other illegal drugs), gambling and gaming behaviours, and Internet and social media use among Italian students, as well as collecting data on psychosocial and sociodemographic variables.

In line with the standardized ESPAD methodology, a multi-stage stratified random sampling was also used in 2024 to ensure a representative sample of students aged 15 to 19 years [7]. The questionnaire was completed by students during a regular class hour, on a voluntary and anonymous basis, using a mixed-mode administration (paper-based and web-based) [8]. The final sample include 20,201 Italian students (51.8% male). A post-stratification weighting method was applied for age and gender, in accordance with the distribution of the target population.

In the present study, descriptive analyses and a multivariate logistic regression (MLR) were conducted. Statistical significance was assessed for the descriptive analyses, with the threshold for significance set at p<0.05. Regression results were expressed as Odds Ratios (OR) with corresponding 95% Confidence Intervals (CI).

The dependent variable considered in the MLR was the use of nicotine pouches in the 12 months prior to the survey administration, with non-users serving as the reference category. A selection of independent variables, based on both the analyses conducted and the relevant scientific literature, was included in the MLR model to identify characteristics associated with nicotine pouch use.

In addition to Age, treated as a discrete continuous variable, and Sex, coded as 0 = males or 1 = females, the independent variables include: daily traditional cigarette use, coded as 0 = no use or 1 = use of at least one cigarette per day in the last year; E-cigarette use in the last 12 months, coded as 0 = no use or 1 = use of e-cigarettes at least once in the last year; Current use of at least one nicotine-based product or device in the 30 days prior to the survey administration, including traditional cigarettes, e-cigarettes, heated tobacco products, water pipes, or snuff. The variable was coded as 0 = no use or 1 = use of at least one product; Cannabis use in the last 12 months, coded as 0 = no use or 1 = use of cannabis at least once in the last year; Binge drinking in the last 30 days, defined as consuming five or more alcoholic drinks on a single occasion. The variable coded as 0 = no binge drinking or 1 = binge drinking; Proximity to traditional cigarette use, coded as 1 = having at least one parent who smokes or 0 = no parent smokes; Proximity to e-cigarette use, coded as 1 = having at least one parent who vapes or 0 = no parent vapes.

To account for the stratification and class-level clustering of the sample, the Complex Samples module in SPSS was used. This method allows for the inclusion of sample stratification variables (geographic area and school), cluster variables (class), and sample weights, providing a more accurate statistical analysis. All statistical analyses were performed using SPSS Statistics 26.

Results

Overall, 6.8% of students have used nicotine pouches at least once in their lifetime (95% CI: 6.5%-7.2%), especially among males (7.7%; 95% CI: 7.2%-8.3%) than females (5.7%; 95% CI: 5.2%-6.1%; p < 0.001).

Usage within the past year was 5.2% (95% CI: 4.9%-5.6%), with higher rates for males (6.1%; 95% CI: 5.6%-6.6%) compared to their female peers (4.1%; 95% CI: 3.7%-4.5%; p < 0.001).

In the last month, 3.0% of Italian students had used nicotine pouches (95% CI: 2.7%-3.2%), with a notable difference between males (3.6%; 95% CI: 3.2%-4.0%) and females (2.3%; 95% CI: 2.0%-2.6%; p < 0.001) (Table 1).

Among students who had never used other nicotine-based products, 0.4% had used nicotine pouches at least once in their lifetime. Additionally, 2.0% of students who had ever used nicotine pouches had not used any other nicotine source in the past month.

The MLR revealed that nicotine pouch use was positively associated with daily traditional cigarette use in the past year (OR = 1.39; 95% CI: 1.02-1.90); use of at least one nicotine-based product in the past month (OR = 4.56; 95% CI: 2.25-9.23); e-cigarette use in the past year (OR = 2.26; 95% CI: 1.34-3.82); cannabis use in the past year (OR = 2.08; 95% CI: 1.46-2.95); binge drinking in the past month (OR = 1.86; 95% CI: 1.27-2.72); and having at least one parent who vapes (OR = 2.24; 95% CI: 1.67-3.02).

Conversely, nicotine pouch use was inversely associated with older age (OR = 0.83; 95% CI: 0.74-0.94); being female (OR = 0.68; 95% CI: 0.48-0.97); and having at least one parent who smokes traditional cigarettes (OR = 0.59; 95% CI: 0.40-0.88) (Table 2).

Discussion

The present study is based on data collected from a sample of students aged 15 to 19, representative of the Italian high school population, and provides the first statistically reliable quantitative estimate of the prevalence of nicotine pouch use in this vulnerable population.

Specifically, the results show that 6.8% of students, corresponding to approximately 170,000 students according to annual data provided by the Italian Ministry of Education, have used nicotine pouches at least once in their lifetime. A total of 5.2% reported use in the past year, and 3.0% in the month prior to the survey administration, amounting to nearly 130,000 and over 74,000 students, respectively. The lifetime prevalence rate is higher than that observed in the United States, where use ranged from 3.5% to 4.1% between 2019 and 2021, and dropped to 2.3% in 2022 and 2023 [1]. However, current usage rates are more comparable, with values around 1.5% to 2.0% between 2019 and 2021, and between 1.1% and 1.5% in 2022-2023 [1].

Consistent with other studies conducted in Germany [9] and the United States [1,10], all usage patterns show significantly higher prevalence among males, reflecting a greater appeal of the nicotine pouches to boys, as is often the case when new products are introduced to the market [11,12].

Usage rates are lower but still not negligible among students who have never tried other nicotine-based products. Specifically, 0.4% of students – nearly 10,000 boys and girls – have tried nicotine pouches without any prior experience with traditional cigarettes, e-cigarettes, heated tobacco products, water pipes, or snuff. These are low but noteworthy prevalence rates, especially considering the novelty of nicotine pouches in the Italian market.

The results of the multinomial logistic regression confirm the association between nicotine pouch use and other nicotine-based products. A positive association was found with daily traditional cigarette smoking, use of e-cigarette in the last year, and having tried at least one other nicotine-based product. These findings align with recent literature showing that users of other nicotine products tend to be curious about nicotine pouches, a curiosity often fuelled by the wide variety of available flavours and the possibility to use them in places where other products (such as traditional or electronic cigarettes) are prohibited [1].

The present study also highlights an association with the use of other legal and illegal substances, such as cannabis and binge drinking. This finding may be interpreted within the broader body of literature on the co-occurrence of different substance use behaviours and, more specifically, on the association between nicotine consumption and other psychoactive substances [13].

Regarding other potential contextual variables, significant associations were found with proximity to traditional and e-cigarette use. Specifically, whereas having parents who used e-cigarettes was positively associated with nicotine pouch use, having parents who used traditional cigarettes showed an inverse association. The first result is not surprising, as parental e-cigarette use may indicate a greater family acceptance of nicotine-based devices and products. By contrast, current literature does not offer interpretive support for the second finding. Parents who smoke traditional cigarettes provide a visible example of smoking behaviour, which contrasts with the more discrete and alternative mode of consumption offered by nicotine pouches. Moreover, e-cigarettes and nicotine pouches share a narrative of modern use and a perception of being less harmful, distancing them from traditional smoking habits, even in terms of the opinion parents may also have and convey about alternative products.

This is the first Italian study to provide prevalence estimates of nicotine pouch use in this population segment and to analyse associated factors such as the use of other nicotine-based products, the consumption of other substances, and variables related to proximity to use. The main strength of these findings lies on their basis on data collected from a large sample representative of the Italian high school student population, using a robust statistical methodology.

However, there are some limitations that need to be acknowledge. The study is based on a self-administered questionnaire, which can introduce common biases such as social desirability or difficulty recalling information. To mitigate these issues, students were strictly guaranteed anonymity, and the questionnaire was administered in a controlled setting. Furthermore, the items specify precise timeframes to facilitate memory recall. Given the cross-sectional design of the study, it is not possible to establish causal relationships, but only to highlight associations between nicotine pouch use and other factors.

In addition to providing a current snapshot of nicotine pouch use among adolescent students in Italy, these results suggest that nicotine pouches may also contribute to the further recruitment of new young nicotine users. This aligns with international observations, where the introduction of nicotine pouches has coincided with an increase in nicotine consumption rather than a substitution [14,15]. The spread of these products highlights adolescents’ vulnerability to new nicotine delivery methods and their marketing, making continuous monitoring and research essential for public health protection [16].

Conclusions

This study provides the first national snapshot of nicotine pouch use among Italian students aged 15 to 19, based on representative data from the ESPAD^®Italia 2024 survey. The results show that a notable share of adolescents have already experimented with this new product, with higher prevalence among boys but a non-negligible presence also among those who have never tried other nicotine-based products.

Nicotine pouch use is associated with other risk behaviours, such as daily smoking, vaping, cannabis use, and binge drinking, confirming a pattern of polysubstance use. Furthermore, familial proximity plays a role: having at least one parent who vapes increases the likelihood of use, while traditional parental smoking appears to have an opposite association.

The data collected suggest that nicotine pouches are not merely an alternative for those who already use nicotine, but may also serve as a new channel of initiation among young people, fuelled in part by the perception of lower harm and the discreteness of their use. In light of these findings, it is crucial to continue epidemiological monitoring of this emerging phenomenon and to promote targeted prevention campaigns capable of properly informing adolescents, families, and schools about the potential risks associated with these new products.

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References

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