BACKGROUND-AIM:
Oral nicotine pouches are entering the market rapidly, hence possibly establishing changed and new use patterns. Often, they are marketed by the industry as smokeless and tobacco-free alternatives to cigarettes which can be used almost anywhere. Additionally, they are small, easy to hide, and don’t smell. However, they often contain high amounts of nicotine, with the risk of young people becoming addicted to nicotine. The aim of this study is to gain knowledge on users and user patterns by comparing characteristics and use behavior among; 1) those using either oral nicotine pouches or cigarettes, exclusively, and 2) exclusive users compared to dual users.

METHODS:
Data were from the §SMOKE study; a nationally representative cross-sectional survey with around 10,000 participants conducted in 2024 among Danish 15-29-year-olds (participation rate 27.8%). The analytical sample included 2,413 youth currently (daily/occasionally) using either nicotine pouches, cigarettes, or both. Use behavior included frequency of use, initiation age, self-perceived addiction, reasons to use, health concerns, use in weekdays and/or weekends and during school hours. We applied logistic regression models adjusted for age and gender to compare exclusive nicotine pouch users with exclusive cigarette users, and to compare exclusive user groups with dual users.

RESULTS:
Overall, 28.6 % used only nicotine pouches, 58.4 % used only cigarettes and 13.0 % used both products. When comparing exclusive nicotine pouch users with exclusive cigarette users, we found that the former were less likely to be female (OR: 0.70), more likely to be 18-24 year old (OR: 1.81), debuting after age 18 (vs. earlier) (OR: 3.30), perceiving themselves as notably addicted (vs. less addicted) (OR: 4.33), always using pouches in school (OR: 4.26), and using both in weekdays and weekends (OR: 2.44). Those only using nicotine pouches had higher odds of reporting ‘due to dependence’ (OR: 2.85), ‘to feel good/high’ (OR: 1.60), ‘to quit other products’ (OR: 3.96) and lower odds of reporting ‘friends are doing it’ (OR: 0.30) as reasons for use compared to those only using cigarettes. Dual users were less often female and in age group 25-29 years compared to exclusive users of both products. Further, they perceived themselves as less addicted to cigarettes than exclusive cigarette users and they were less likely to use cigarettes on both weekends and weekdays than exclusive cigarette users.

CONCLUSIONS:
We observed a clear difference in use behavior among those using only nicotine pouches, cigarettes or both. Boys more often use the products exclusively or in combination. The findings support the incessant nature of nicotine pouch use, i.e., used during school hours. Furthermore, perceived addiction is markedly higher among nicotine pouch users, which – combined with the high nicotine content - pose a serious threat to adolescents’ health.