Study sample characteristics.

Background
Oral nicotine pouches (ONPs) are novel products, gaining popularity and marketed as “tobacco-free” alternatives to cigarettes and smokeless tobacco (SLT), but their public health impact is unknown. This study qualitatively examined ONP appeal and perceptions among cigarette smokers and SLT users from Ohio Appalachia.
Methods
In 2022, we conducted 10 virtual focus groups with smokers (n = 19) and smokeless tobacco users (n = 18) from Appalachia Ohio aged ≥21 to examine perceptions of risks and benefits, substitutability for cigarettes and SLT, and ONP marketing. We transcribed focus groups verbatim, thematically coded transcripts, and analyzed coded data for prominent themes.
Results
Participants perceived ONPs to have similar or less risk than cigarettes/SLT but prominently discussed gastrointestinal and cardiovascular risks. Addiction risk was thought to be comparable to cigarettes/SLT, citing “nicotine is nicotine.” Participants viewed ONPs to be situational rather than complete substitutes for cigarettes/SLT, viewing them as “cleaner,” more socially acceptable, and discrete. Despite appealing features of ONP marketing, participants surmised ads would appeal to youth, new users, tobacco users seeking to cut down/quit, or to “high class,” “white-collar” demographics.
Conclusions
Participants’ perceptions of ONPs and their marketing suggest ONPs are more likely to be used as situational versus complete substitutes for cigarettes and SLT. While situational substitution could exacerbate disparities in Appalachia by facilitating more frequent tobacco/nicotine use, complete substitution could reduce disparities. Research is needed to understand how perceptions, the appeal of ONP marketing, and novel product features translate to patterns of use to understand ONPs’ potential impact.